Numerous fractures of varying ages to a 3-month-old child in July 2015. Alex was taken to hospital by the parents, reporting Alex was not moving their right arm. A skeletal survey revealed fractures indicative of non-accidental injury. Alex's mother had a difficult childhood and was a Looked After Child; she experienced low mood and anxiety during adolescence. Alex's father was not known to agencies; he told two professionals he had learning difficulties but this is not recorded in his records. Ethnicity or nationality not stated. Findings: a gap in multi-disciplinary working within health and information sharing across disciplines and agencies; in the case of young vulnerable parents the step-down process from Child in Need to Early Help should have been more robust; there should be guidance to social care staff to highlight issues of injury which should be evaluated prior to closure or transfer; bruising in non-mobile babies is a cause for concern which should result in a safeguarding referral. Uses a modified version of the systems methodology developed by the Social Care Institute for Excellence. Recommendations: Child in Need (CIN) meetings should be routinely attended by Health Visitors where the child is under 12 months of age; CIN meetings should be given priority by all professionals; to explore with Children's Social Care and GPs a system to notify General Practice when a family is at CIN level; all agencies should take full account of the influence that fathers have on the family and any vulnerabilities or risk factors feature in assessments, referrals or interventions.
      
 Title:  Serious case review in the case of Child Alex. LSCB: Liverpool Safeguarding Children Board Author: Liverpool Safeguarding Children Board 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.                           1  LIVERPOOL SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW IN THE CASE OF CHILD ALEX   REVIEW PERIOD SEPTEMBER 2014 TO JULY 2015   Overview Report – Final            2   CONTENTS               Page  1. Background and Introduction    2-7  2. Timeline and Key Events     8-10  3. Summary and Professional Narrative  11-14  4. Key Themes        15-16  5. Agency Learning       17-21  6. Findings and Recommendations   22-24        3   1  INTRODUCTION AND BACKGROUND TO THE REVIEW  1.1 Key People Person Referred to as: Child Victim Alex Mother of Alex Mother Father of Alex Father  1.2 Incident Leading to the Review In July 2015 Alex was taken to the local Children’s Hospital with the parents.  They reported that Alex had not been moving their right arm since early that morning and that they had noticed a bruise to the right elbow.  They provided no history of previous trauma.  Alex was three months old at the time. Alex was examined and x-rays revealed a current fracture of the distal humerus and abnormal periosteal reaction on the right distal radius.  Further medical assessment recorded healing posterior rib fractures and healing lateral fractures.   A full skeletal survey was undertaken the following day which revealed numerous fractures of varying ages which were thought to be highly indicative of non-accidental injury. 1.3 Confidentiality  Alex’s gender is not referred to in this report. Pseudonyms are attributed to other key individuals and to professionals who worked with Alex and their family.    1.4 Background to Alex and Family Alex was born in March 2015 by emergency caesarean section.  There were no complications at birth and Alex and mother were discharged from hospital to the care of community based services.  Alex is the only child and both parents were described by professionals as young and inexperienced. Alex’s mother had experienced mental health issues as a young person.  She had experienced a difficult childhood; her mother was a drug user which led to the family being subject to child protection planning and Alex’s mother becoming a Looked After Child. During her adolescence she continued to experience low mood and anxiety for which she was prescribed anti-depressant medication.   After leaving care mother lived with both maternal grandparents until maternal grandmother died in 2015.  Alex’s mother and maternal grandfather continued living in the same home.  Alex’s father came to live with them and this arrangement continued throughout the pregnancy and after Alex’s birth. 4  Alex’s father was not known to agencies and there is little information available about his background.  He was registered with a local GP who noted that on occasions he could be demanding and aggressive in consultations.  There is no record of any specific medical conditions and consultations appear to be routine.  He changed GP to the same practice as mother when he moved in with her.   He told at least two professionals that he had learning difficulties although this is not recorded in his medical records.   From birth Alex lived with their parents at the home of maternal grandfather.  They were visited at home frequently by professionals including health visiting services and an Enhanced Midwife. Due to mother’s previous vulnerabilities the family were subject to Child in Need for the first six weeks after Alex’s birth.  The family were referred to Early Help Services in May 2015 following step-down from Child in Need. The incident leading to this review took place in July 2015.  1.5 Rationale for conducting the SCR Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the procedures that are set out in chapter four of Working Together to Safeguard Children (2015).  An LSCB should always undertake a serious case review when a child dies or has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the Board or other relevant persons have worked together.   The purpose of the review is to establish what lessons can be learned from the case to improve safeguarding in the future, to improve inter-agency working and to better safeguard and promote the welfare of children in the local area.  This serious case review has been conducted under the guidance set out in Working Together to Safeguard Children (2015)1. The principles underpinning the review are that it:  Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;   Is transparent about the way data is collected and analysed; and                                                            1 Working Together to Safeguard Children, Department for Education (Revised2 015)  5   Makes use of relevant research and case evidence to inform the findings. The review was conducted on the basis that the overview report would be published in full.   1.6 The scope of the SCR The period under review is from September 2014 to July 2015.  Relevant background and contextual information prior to September 2014 is included in this report but is not subject to analysis.  1.7 Agencies Participating in the SCR   The following agencies have provided information and contributed to the SCR in accordance with Working Together to Safeguard Children (2015), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks.   Children’s Social Care (CSC)  Health Visiting Services (HV)  GP  Police  Midwifery and Maternity Services  Hospital Services  1.8 Practitioners Involved in the Review  Practitioner Service Interviewed GP General Practice Yes HV1 Health Visiting No HV2 Health Visiting Yes EMW Enhanced Midwife Yes  CCW Children’s Centre Worker Yes SW Social Worker CSC Yes SWM1 Social Work Manager CSC Yes SWM2 Social Worker Manager CSC Yes CP1 Careline Practitioner Yes CP2 Careline Practitioner  Yes HC Hospital Consultant Yes   1.9 Methodology The review was commissioned by the Local Safeguarding Children Board who appointed a Lead Reviewer to undertake the review using a modified version of the systems methodology developed by the Social Care Institute for Excellence. 2                                                             2 http://www.scie.org.uk/publication 6  A multi-agency chronology was compiled to support the Serious Case Review which contains information about mother’s contact with agencies dating back to 2014. The lead reviewer held one to one and group conversations with professionals from all agencies included in the chronology.  1.10 Research Questions Systems reviews do not set specific terms of reference.  The following research questions were posed by the LSCB to assist in providing focus to the review and constructing and shaping the findings. The LSCB asked the panel to address the following questions in the review:  What was the role played by services before and after birth?  How well did agencies communicate?  Was mother’s mental health appropriately assessed and managed?  How robust was the decision to step down to Early Help and how was the transition managed? 1.11 Review Team Members  A serious case review team was convened consisting of senior and specialist agency representatives from the local area to oversee the collation and analysis of information and outcomes of the review. The review was co-ordinated and managed by an independent lead reviewer with appropriate experience and training.  Position Organisation Service Manager Children’s Social Care Service Manager Careline (the ‘front door’ service for Children’s and Adult’s Social Care) Lead Nurse for Safeguarding x 2 Clinical Commissioning Group Head-teacher Primary School  Detective Chief Inspector Merseyside Police Lead GP for Safeguarding General Practice Business Manager LSCB Training Coordinator LSCB Education Liaison Officer  LSCB Named GP for Safeguarding General Practice Executive Support Officer LSCB – Administration and Minute Taker    7   The independent lead reviewer chaired the review and attended every meeting of the review team.   The review team met on five occasions to oversee the review process, analyse data, report to the LSCB, draw conclusions from the material analysed and oversee the production of draft and final reports.  Written minutes of the review team meeting discussions and decisions were recorded by the LSCB Business Support Officer.  The review has used a systems based approach to analysing information and presenting the findings in the final chapter using recommended best practice in identifying improvement and learning.   The review team identified information to be provided by individual agencies.  This included all relevant documents and reports from services working with Alex in regard to assessments, plans and interventions.  1.12 Involvement of Family, Friends and Significant Others At the time of writing this report legal constraints prevent the review speaking to mother and father. 1.13 Criminal Investigation Police are currently undertaking a criminal investigation into the incident that led to this SCR. 1.14 Current Safeguarding Alex has recovered from his injuries and is now subject to a full care order.             8  2 TIMELINE OF AGENCY INVOLVEMENT AND KEY EVENTS 2.1 2014  In late September mother presented at the GP surgery and saw the community midwife who confirmed mother’s pregnancy. A week later mother attended the A&E department of a local hospital reporting that she was feeling unwell.  She said she was three months pregnant and that she had not felt the baby move for three days.  She was examined and reassured about foetal movement in early pregnancy. In November mother attended the local women’s hospital for booking; she was 18 weeks pregnant which is considered to be a late booking.  She was assessed as requiring additional support with the pregnancy as she had a history of contact with mental health services as a young person.  She was offered the services of an Enhanced Midwife and was referred to the perinatal mental health team. 2.2 2015 In early January mother was seen by a consultant psychiatrist in the perinatal mental health team.   One month later the Enhanced Midwife made a referral to Children’s Social Care for a pre-birth assessment four weeks before Alex was born. In early March a pre-birth assessment was conducted by CSC. This noted mother’s vulnerabilities and that an Enhanced Midwife would be working closely with the family. In late March Alex was born by emergency caesarean section and without complications at the local hospital.  It was noted that mother needed additional support following the birth as she was anxious.  Mother and baby were discharged two days later. Alex was admitted to a local Children’s Hospital at the beginning of April.  A routine paediatric liaison form was completed and the Health Visitor and GP were informed of the admission. It is not current policy to inform maternity and midwifery services therefore this was not done.  In April a birth visit was conducted by HV1.  No concerns were noted; it was observed that Alex was doing well and parents were responding to their needs appropriately. Eight days after the birth visit the Enhanced Midwife made a home visit and noted a small mark on the left side of  Alex’s chest that ‘looked like a bruise’, there were some other small reddish marks on Alex’s body.  When asked about the marks mother said that they appear and disappear3. The Enhanced Midwife made a referral to the GP who reviewed Alex and made a referral to the local Children’s Hospital to investigate a possible blood disorder.                                                            3 http://cks.nice.org.uk/bruising#!goals 9  One week later Alex was seen by the GP with a rash.  A review was arranged for the following day however mother did not attend the appointment and said that she would follow up with the midwife.   Four days later both parents attended the A&E department of the local children’s hospital with Alex saying that Alex had a widespread rash.  Alex was examined and blood samples were taken which were within normal range.  Doctors wanted to admit Alex but parents refused the admission and it was agreed that Alex could go home with a follow up appointment in the ambulatory clinic.  Three days after this CSC held a meeting to discuss the needs of the family. SWM1 recommended that a Child In Need meeting was required to ensure appropriate support for the family.  SWM1 felt the family had some vulnerabilities relating to mother’s background and that the parents were young and inexperienced.   Two days later SW1 and EMW conducted a home visit to discharge Alex and mother from midwifery care.   Five days later a Child In Need meeting was held at the family home; it was agreed by the meeting that there was no further role for CSC and that the family would be ‘stepped down’ to Early Help (EHAT). Two days after the step-down referral a follow up visit to the clinic at the local Children’s Hospital was missed by the parents and a letter was sent to parents and GP informing that another appointment would be made. Over the next two weeks Alex was seen by HV2 and the GP on a number of occasions.  HV2 discussed appropriate feeding, it was also observed that there was an adult sized pillow in the ‘Moses Basket’ and HV2 discussed safe sleeping.  Mother said she understood the need to remove the pillow.  HV2 telephoned CSC to check regarding the closure of the case in view of mother’s history and discussed the EHAT referral. At a home visit the following week HV2 observed Alex to be clean and warm and noted excellent communication between parents.   Three weeks after the step-down referral the Children’s Centre undertook an announced home visit to introduce the service and conduct an Early Help assessment.  The parents were not at home and the worker spoke to maternal grandfather who said that they were in the process of leaving.   In late June Alex was seen at the GP surgery presenting as ‘generally unwell’.  Alex was seen by a locum GP who advised that Alex be taken to the local children’s hospital as they had a high temperature. Parents declined an ambulance to take Alex to hospital and said that grandfather would take them, however parents did not take Alex to hospital.   This was not known to the GP until several weeks later as the GP had not made a referral or rung A&E to say that Alex was being brought to hospital.  If a referral had been made then A&E would routinely notify the GP of the failure to attend. 10  In early July at a home visit by HV2 mother reported that she had concerns that Alex was having hand and foot spasms, HV2 discussed these concerns with mother and suggested that she contact the GP who could look into this further if necessary. The following day mother attended A&E at the local hospital with a fracture to her left wrist which she said she had sustained in a fall. It was noted that mother took anti-depressant medication. She attended hospital again one day later saying that the cast was uncomfortable and then again two days after that asking for the cast to be removed.  The A&E record showed a ‘long history’ of fractured wrists. Three days after this Alex was seen at home by HV2, a small red mark under the eye was noted which mother said was a scratch. Three days after this mother attended A&E with anaphylactic shock after having eaten something that created an allergic reaction. Two days later father attended the local A&E department complaining of shortness of breath.   The following day HV2 visited the family at home and no concerns were noted.  The previously reported hand and foot spasms were discussed and HV again advised contacting the GP.  (In a later statement to police mother denied that a visit had taken place on this day, saying that the visit had been the day before). In mid-July on the day after HV2’s visit, the incident leading to this review occurred.                11  3.  PROFESSIONAL NARRATIVE Mother had been known to services since childhood; she was a Looked After Child and had been involved with Child and Adolescent Mental Health Services.  She had experienced mental health episodes and receiving both inpatient and outpatient treatment.  When she left care mother had gone to live with her grandparents.  She had little contact with her own mother who had a history of drug misuse, which had been the reason for mother becoming looked after.   Mother’s GP had known her for some time and described her as often being very anxious.  She was a frequent attender at the surgery and had a history of verbal aggression to the GP.  The GP reported that mother was demanding in terms of medication and became difficult and aggressive when this was refused. In the early stages of pregnancy mother experienced some difficulties and attended A&E on two occasions with concerns about the unborn baby not moving at which she was reassured about foetal movement in the first trimester of pregnancy.  She also experienced some bleeding for which she referred herself to the hospital. When she presented to her GP in September 2014 mother was confirmed as being pregnant and was referred to the local Women’s Hospital for maternity and midwifery services although mother did not complete her ‘booking in’ until she was 18 weeks pregnant.  At this appointment mother’s mental health history was noted as was her previous Looked After status and she was offered support from an Enhanced Midwife which she accepted.  She was also referred to the perinatal mental health consultant whom she saw for a first appointment in January 2015. The Consultant Psychiatrist reviewed mother’s mental health and medication and found her to be well and looking forward to having a baby. The consultant recommended continuing on anti-depressant medication and offered to review mother again if required.  During pregnancy her anti-depressant medication was managed both by the consultant psychiatrist whom she saw on one further occasion and by her GP.  The pregnancy was otherwise uneventful and mother and father presented as being excited about the birth and looking forward to the arrival of the baby.  At this time they were living with maternal grandfather and hoping to secure their own property when the baby was born.  The EMW was seeing mother at regular appointments and father was present at most of the visits (although this was not always recorded).  He was interested in the pregnancy and looking forward to the baby’s birth, he asked a lot of questions about looking after the baby.  EMW observed that it took some time for father to understand responses to his questions and that father was always open and honest about his learning disability.4 When mother was 36 weeks pregnant, the Enhanced Midwife made a referral to CSC requesting that a pre-birth assessment be undertaken based on mother’s previous vulnerabilities.  The EMW reviewed mother’s notes and decided that this was necessary, although it was later in the pregnancy than usual to make such a referral.                                                            4 There is no medical record of father having a learning disability however a number of professionals said that father self-reported learning difficulties to them. 12  On receipt of the referral the case was allocated to a SW who went to visit mother and father at maternal grandfather’s home with EMW.  SW observed that mother was quite anxious about seeing a social worker at first which he attributed to her previous experience of being a Looked After Child, however he noted that mother was open and honest once the relationship had built up.  Mother talked about her own childhood experiences and recognised the risks of contact with her own mother. Mother and father said that they had some apprehension about the birth of the baby but nothing out of the ordinary for a young couple.  They said they were both excited and looking forward to having a child. In March Alex was born by emergency caesarean section; the midwife on the ante-natal ward noted that mother was anxious after the birth and had to be reassured to stay in hospital as she had asked to be discharged.  There had been no complications at birth and both mother and baby were discharged into the care of EMW and Health Visiting services.  The first birth visit by a Health Visitor took place in early April 2015.  (The Health Visitor who undertook the first post birth visit was not available to contribute to the review as she has now left the role).  At that visit there were no concerns noted with regard to Alex or mother.  Mother’s mental health and care history was noted as was the involvement of EMW and SW.  The family were subject to Child in Need at this time. When HV2 went out to conduct a second visit in April 2015 she was aware of mother’s background and vulnerabilities.  The family were still living at the home of maternal grandfather and the home conditions were observed to be good.  HV2 had no concerns about Alex who was clean and well presented.  The interaction between baby and mother was good.  HV2 noted some concerns about feeding as Alex was being overfed which was addressed with mother.  She had taken Alex to the GP with reflux which demonstrated to HV2 that she had parenting skills. HV2 observed that it is not unusual for new parents to overfeed babies and a plan was put in place to address that which was understood by mother.  In early May SW and SWM1 discussed the case; SW felt that the family were doing well.  SWM1 noted the previous vulnerabilities and felt that a CIN meeting should be arranged as the family would benefit from a CIN plan.  It was agreed that a CIN meeting would be arranged at the home address and from there consideration could be given to ongoing support through EHAT.  Two days later EMW and SW undertook a home visit to discharge from midwifery services.  They noted that Alex’s weight was good and that a review was due in the medical clinic in relation to a possible blood disorder.5 A CIN meeting took place seven days later which was attended by SW, EMW, mother, father and maternal grandfather. It was agreed that there were no concerns about Alex from SW or EMW and it was decided that there was no role for CSC and that the CIN should be closed and a referral to Early Help (EHAT) should be made. The family were in agreement with this and                                                            5 This was in relation to a referral made by EMW when she saw what ‘looked like a bruise’ at a home visit in late April 2015. 13  said they would engage with the Children’s Centre.   A referral was made to the local Children’s Centre setting out the support needs of the family.   The support needs identified were for the Children’s Centre to help the parents apply for a new property and relevant benefits; for the baby to catch up the missed immunisations; for the parents to attend debt management sessions at Citizen’s Advice Bureau and for the family to attend for activities.  This had been discussed with the family by SW and EMW and they had said they were happy to engage with the Children’s Centre. HV2 was informed by mother that CSC were closing the CIN and that the family were being referred to EHAT. Because of the mother’s previous history HV2 wanted to ensure that the service was in place and that the family were going to engage.  She rang CSC and spoke to the SW who informed her that the referral had been made to the local Children’s Centre. HV2 knew the worker who was taking the referral and was satisfied that a good service would be offered. HV2 discussed the EHAT referral with both parents and they said they were more than happy to engage with the Children’s Centre.  HV2 was aware that parents will often say they will engage and not do so but noted that they were both eager.   HV2 had no concerns about Alex however she was aware that both parents were not fully aware of developmental milestones and their expectations of the baby were unrealistic. They had said that Alex was very strong and was trying to sit up but was around 7 weeks old at this time. HV2 discussed expectations in detail and strongly advised that the parents should attend baby classes at the Children’s Centre.  HV2 discussed expectations in relation to development and age appropriate play was discussed.  Mother reported that she had recommenced anti-depressant medication and that she received support from partner and grandfather.   The Children’s Centre received the referral from SW, and CCW made a home visit to introduce the service in early June.  Both parents were out at the time of the visit and CCW spoke to maternal grandfather who said that the parents were hoping to move into their own property as soon as they could.  Another appointment was arranged for two weeks later however parents were not at home when the CCW visited; CCW rang mother’s mobile phone and left a message for her to make contact, which she did the following day. CCW needed to complete an EHAT referral form which sets out the plan for working with the family.  The parents were very focused on getting a new property and wanted to prioritise this.  CCW saw them at the beginning of July to complete housing applications and then again to complete forms for benefits.  Both mother and father told CCW that they had trouble completing forms and CCW did this on their behalf. The EHAT form was completed several days later and needed to be done in two sessions as mother and father were attending other appointments related housing.  They had been offered a property and were preparing to move in. 14  CCW reflected that the family really only engaged in relation to their housing needs.  However CCW was able to speak to HV2 about Alex’s immunisations as she provided a session at the Children’s Centre once a week.   At HV2’s next visit she was informed by mother that the family would be moving to a new home and that she had been engaging with the Children’s Centre who had completed the housing forms with them. At the visit mother informed HV2 that Alex was having hand and foot spasms, HV2 discussed this and explained that mother should continue to observe Alex and that she should inform the GP about her concerns. HV2 saw Alex in early July and everything was going well and was gaining weight and thriving and there were no concerns.   The review did not speak to professionals about presentations to A&E by mother and father in the three days prior to the incident leading to this review, however these events are recorded in section 2 above.6 This was followed by a visit in mid-July (mother has subsequently denied that this visit took place and that HV2 attended on the day before).  HV2 has reflected on why mother might deny this but can think of no obvious reason. At that visit HV2 saw Alex clean, warm and appropriately dressed and they were both eager to demonstrate that Alex was starting to walk.  Alex was just under 15 weeks old.  HV2 noted that father held Alex up appropriately and just let the feet go to the floor, HV2 again explained that they must not try to let the baby stand and that Alex would not be able to walk until around nine months old.  The following day the incident leading to this review took place.                                                                      6 There is no inference that these events are connected to the incident leading to this review however the panel wished to highlight that parents made four visits to A&E regarding health issues in the four days prior to the incident. 15  4. KEY THEMES IDENTIFIED BY THE REVIEW The review has identified a number of key themes from which learning can be gained, these are shown below.  The review has also identified specific learning for each agency which is shown at Section 5 of this report. 4.1 Bruising in non-mobile babies Bruising was observed by EMW and by the GP.  Neither made a safeguarding referral to CSC. The guidance7 in relation to bruising in non-mobile babies is unequivocal and states that any bruising in non-mobile babies is a potential indicator of risk and that a safeguarding referral must be made where it is present. 4.2 Parents with Learning Difficulties Both parents told professionals that they had learning difficulties.  Mother reported that she had dyslexia and father said he had difficulty in understanding information that was given to him.  Both said that they had difficulty in completing forms and asked a worker at the Children’s Centre to do this for them.  Mother’s medical notes refer to her as having dyslexia however there is no record of father being identified as having a specific learning disability. Both parents exhibited a lack of understanding and over-expectation in relation to Alex’s development; both thought that Alex was trying to sit up on their own at just seven weeks old and both were encouraging Alex to walk when they were fifteen weeks old.  HV2 talked to both parents about developmental milestones and age appropriate play, and reminded them both that they should not try to sit Alex up on their own or to stand them up.  HV2 observed that both parents appeared to understand safety advice given to them and to act on it, however it is of concern that by fifteen weeks old their expectations of Alex’s mobility were still unrealistic. There is no indication that unrealistic expectations or a lack of parental understanding of developmental milestones was discussed between HV2, EMW and SW1.  The step-down to the Children’s Centre did not include any observations about parenting capacity.  This would have been valuable information as it had the potential to impact on Alex’s safety. 4.3 Professionals involved in CIN meetings SW1 and EMW were the only professionals involved in CIN meetings.  Other professionals working with the family, specifically HV2 was not invited to attend meetings, which resulted in important information about the parents and Alex not being shared in a timely fashion. There is no specific guidance in relation to how many professionals should attend CIN meetings however it is the view of the panel that in cases where a child is under school age the Health Visitor should always be invited to attend CIN meetings.  Where a child is of school age the school nurse should always be invited to attend CIN meetings.                                                            7 7 NICE (2009) ‘When to suspect child maltreatment’, clinical guideline 89, Manchester: NICE.   16  Both mother and father had vulnerabilities and risk factors which were recognised by professionals.  Mother had a known history of mental health problems for which she was appropriately treated by her GP.  Her additional needs were noted during pregnancy and she received services from an Enhanced Midwife. 4.4 Step-Down to Early Help  The step-down from CIN to Early Help took place after one Child in Need meeting which did not include all professionals who had been involved with the family.   HV2 was aware of the step-down and was proactive in making enquiries to satisfy herself that the family would engage.  This was good practice. CCW arranged a home visit to the family following referral but they were not at home, a second home visit was undertaken but again the family were not at home. A recommendation is made in relation to the step-down process where families have ongoing vulnerabilities, learning difficulties and do not respond to initial attempts at engagement.                    17  5  ANALYSIS OF AGENCY ACTIONS AND LEARNING  5.1 General Practice Alex’s parents were registered with different GPs until shortly before Alex’s birth.  The review spoke to mother’s GP and received information via a panel member in relation to father’s GP.   The relationship between mother and her GP was a difficult one.  Mother could be demanding and had reacted aggressively with her GP when she had been refused medication.  The GP felt that mother was too young to receive high doses of pain killing medication when mother said that she had pain in her joints.  There is no evidence of these symptoms being investigated further. Father had been registered with the same GP practice for some time until he changed to mother’s GP when he moved in with her.  His GP reported that he could be demanding and aggressive in consultations. When the GP saw Alex one month after birth with a rash a review was arranged, Alex was not brought to this appointment and the GP followed up with a phone-call which was good practice.  Four days later the GP saw Alex again with the same rash and made a referral to the Emergency Department at the local children’s hospital.  The parents refused to have Alex admitted and left the hospital.  The GP was not notified that Alex had not been admitted until a notification letter was received ten days later. Mother attended the GP in mid-May saying that she was suffering from low mood after stopping anti-depressant medication in March.  The GP saw mother again for a post-natal check two weeks later, however there was no exploration of mental health or social support. In late June Alex was brought to the GP surgery and was described as being generally unwell. A locum GP checked Alex and told parents that Alex needed to attend the local hospital with a view to admission.  The parents declined an ambulance saying that grandparents would drive them to the hospital. They also asked the GP to obtain a second opinion from another doctor in the practice, this request was refused as the GP was of the firm opinion that Alex should be taken to hospital.  The parents did not take Alex to hospital and did not inform the GP.   The GP did not follow up whether Alex had been taken to hospital as a referral had not been made.  Although it is usual practice not to follow up unless a referral has been made, the review panel conclude it would be good practice for GPs to follow up in such circumstances, particularly given Alex’s age at the time and the known vulnerabilities within the family. The panel feel it would also be good practice for the GP to notify Health Visiting Services so that a record can be kept of children whose parents do not act on medical advice.  The GP records evidence a wealth of information about all members of the index household. This includes evidence of myriad vulnerabilities exhibited by both parents. Mother presented frequently at the GP surgery and was difficult to manage often demanding. There were threats of self-harm and involvement of secondary mental health care services.  18  She was jointly managed by primary care and a consultant psychiatrist within the local maternity unit.  She was known to have had adverse childhood experiences.  Father was recorded as having learning difficulties. He had changed registration to mum’s practice before Alex was born.  The GPs received Health Professional Communications from the maternity unit detailing the safeguarding risks, but the management of these risks was lacking.   The practice holds monthly safeguarding meetings with HVs. Pre-birth safeguarding concerns were highlighted at these meetings. Safeguarding risks appear to have been managed by midwifery services in conjunction with the LA without any involvement of general practice. This illustrates a potential gap in multi-disciplinary working within health and information sharing generally across disciplines and agencies. Recommendation regarding systems to notify General Practice when a family is at CIN level.  5.2 Maternity and Midwifery Services Mother did not book in with the service until she was 18 weeks pregnant.  The service demonstrated good practice in assessing mother’s mental health needs and referring her to peri-natal mental health services.  The service made a referral to Careline for a pre-birth assessment due to mother’s history, however the referral did not take place until 18 weeks after booking (at 36 weeks pregnancy) which left a short time for the assessment to take place and for a robust plan to be put in place.   When EMW noticed slight bruising to Alex’s chest at a home visit when Alex was four weeks old she referred the baby to GP and for review.  Guidance relating to bruising in immobile babies8 recommends that all professions recognise this as a risk factor and that a safeguarding referral is made. This did not take place and was a missed opportunity.  There is nothing in the CSC record that this event was discussed with or recorded by SW, nor is there any record of it being discussed with HV2.  Recommendation regarding guidance on bruising in immobile babies and safeguarding. The decision to step-down from CIN to Early Help was made jointly between EMW and the SW at a CIN meeting.  The review panel feel that in the case of young vulnerable parents there should be a more robust step-down process and a recommendation is made in this regard. The panel also recommend that where a child is less than 12 months old the Health Visitor should be routinely invited to CIN meetings.                                                               8 http://cks.nice.org.uk/bruising#!diagnosisadditional 19  5.3. Health Visiting Services The initial birth visit was conducted by HV1 who has since left the service.  HV2 took over care of the family and was aware and responsive to the vulnerabilities identified at the birth visit.  HV2 spent considerable time with Alex and both parents and appeared to develop a constructive and objective relationship with them.  Mother was open and honest with HV2 regarding her own background and shared her anxieties and concerns about some aspects of Alex’s health and wellbeing with HV2.  HV2 provided appropriate advice, information and support in response to mother’s anxieties.   She noted concerns on a number of occasions in relation to Alex being overfed, presenting with a rash and on two occasions in relation  to parental understanding of developmental milestones. HV2 took appropriate action on every occasion and followed up her recommendations when she next saw mother and father.  On one occasion HV2 noted that Alex had a red mark beneath the eye which mother said was a scratch, this was noted in the record but no further action was taken as HV2 was not concerned that this was a safeguarding issue. HV2 liaised appropriately with other services and was proactive in discussing the ‘step-down’ from CIN to EHAT.  HV2 did not attend CIN meetings; it is not clear whether she was invited to attend which may have been useful in providing a more complete picture of the family’s functioning and coping skills.    5.4. Children’s Social Care Five weeks before Alex was born CSC received a referral for pre-birth assessment from Midwifery and Maternity Services.  SW made contact with mother and father within the required timescale and went to visit them at maternal grandfather’s home.  The assessment was thorough and identified mother’s vulnerable history and relationship with her mother as an ongoing vulnerability.  This was good practice. The SW remained involved with the family until five weeks after Alex was born, attending two home visits both of which were conducted with EMW.  At the second home visit SW recorded that in light of there being no concerns regarding Alex, parenting capacity or capability and that EMW would remain involved with the family, there that there was no further role for CSC and that the case should be stepped-down.  This was discussed with the family and a final CIN meeting was arranged.  This decision appears to have been based on ongoing contact with the family and no concerns about Alex, however there is no evidence of consideration of the bruising that was seen by EMW in early March.  This was a missed opportunity to share information about a potential safeguarding concern. Whilst the case was open to SW it was managed by two SW managers in the assessment service.  In late February SW transferred department and took the case with him. SW1M had reviewed the case with SW and felt that it was necessary to continue to support the family through CIN and that there remained some risk and vulnerability factors.  When SWM2 took over management he also reviewed the case with SW and agreed with the proposal that the 20  case should be closed to CSC and stepped down to EHAT.  The difference in management perspective on the case could be relate to the passage of time and continuing lack of any concerns, however the review team feels it would have been good practice for the two managers to meet about the case and record the rationale for the difference in their perspectives. There is no evidence of anything other than a written communication between SW and the Early Help Service.     5.4.1. Agency Learning Bruising With regard to the significant event of bruising to the child a number of learning points are noted. The Health economy is complex with many partners potentially recording information on a number of different systems.  Action: There should be guidance to social care staff to highlight any issues of injury or alleged injury that highlights this as a significant event and these should be evaluated prior to closure or transfer.  This will ensure that the incidents are given consideration that is proportionate to the incident and any ongoing risks.  Step Down Process The case was closed to social care at a CIN meeting and referred to a children’s centre on a form. At the same time the enhanced mid wife was finishing her involvement leaving the health visitor as the service.  This means social care do not know if the case is being picked up and if the family has engaged in Early Help services. This could be resolved in a process to step down cases from CIN to Early Help with the process including more than a written communication is not enough - if the social worker refers it how does anyone know the work has been done or the family has engaged?   Action will be taken to ensure that the transfer from CIN to Early Help is robust and that there are transitional arrangements where the family has specific vulnerabilities such as mental health or learning difficulties and also parenting assessments. This should include who is invited to the CIN meeting which agrees to step down – in this case the SW and enhanced midwife were the only agencies with family members – the health visitor was not there. The recommendation would be about who is invited – always school, health visitor and school nurse whichever is age appropriate, and the proposed lead professional whether it is through a children’s centre or an early help hub. This means the CIN meeting is effectively a handover meeting in which the family is introduced to early help services and understands the case is being stepped down as they agree to engage. In addition the GP should always be informed about CIN cases.  There was also a difference in management perspective when the case moved between 2 assessment teams and it would be recommended that managers should meet to discuss transfers. 21  A process will be agreed, briefed to all staff in the Assessment Service and Early Help, which means social care know that the case is progressed the family has engaged in Early Help services. The process to step down cases from CIN to Early Help will include a written communication by the social worker and transitional arrangements particularly where the family has specific vulnerabilities such as mental health or learning difficulties and also parenting assessments.  The process will include inviting school, health visitor and school nurse (whichever is age appropriate) ,and the proposed lead professional whether it is through a children’s centre or an early help hub, to the CIN meeting which agrees to step down. It would also include that the GP would always be informed about open CIN cases and closures.  Ensure a process and guidance for managers to meet about case transfers between teams/ services and differences of perspective. This should include managerial oversight set out in a transfer summary highlighting any significant concerns or events to be evaluated prior to transfer or closure.  5.5 Children’s Centre Following receipt of the referral and request for EHAT from CSC the Children’s Centre arranged a home visit in early June however only grandfather was at home.  Following a second failed visit the worker telephoned and left a message, to which mother replied.   The referral from CSC said that the family needed help with completion of housing and benefit forms, that Alex needed to have immunisations and that the parents needed to attend debt sessions with Citizens Advice Bureau.   It took three weeks from first contact for the family to make contact with the worker following which both parents were strongly focused on completing housing forms and later completing forms for housing benefit.  Both parents said that they had difficulty in reading and writing and that they needed the assistance of the housing worker to do this.  They were keen to move out of the home they were sharing with maternal grandfather and therefore the house move was a priority for them. The parents missed the first appointment to complete the EHAT form due to an appointment about the house move.  The EHAT referral form was completed in two halves on consecutive days.  Once completed the EHAT form goes onto the shared system so that it can be viewed by other professionals.  5.5.1. Agency Learning  That the step down process was not robust and that where there is a proposal to step down the proposed EHAT initiator/lead professional (whether via Children’s Centre or the ‘Hub’) should be invited to the CIN review were step down is being discussed. This would ensure an effective handover and an opportunity for the family to be introduced to the Early Help 22  Agency.  This would also provide the opportunity to clarify with the family that the step down is contingent upon the family engaging with the identified service. That the process for stepping down cases is reviewed to ensure that all partners/ professionals are included in CIN meetings That discussion takes place to ensure that EHAT initiator/ lead professional are fully aware of all aspects of the family history That the children centre process is reviewed to include actions in relation to none-engagement in services agreed at the Child in Need Review, and the need for referral to Children’s Social Care                        23  6. FINDINGS AND RECOMMENDATIONS The review panel has seen evidence of good practice in the following areas: Maternity and midwifery services acted on previous vulnerabilities when mother was assessed for ante-natal care which resulted in referral to an enhanced midwife and to perinatal mental health services.   The pre-birth assessment conducted by CSC was thorough and took account of mother’s history and ongoing vulnerabilities. HV2 demonstrated good practice in making contact with the Children’s Centre following the step down from CIN to Early Help. The review has also identified areas where practice could be modified as a result of learning from this case.    6.1 FINDING 1 Bruising in non-mobile babies is a cause for concern and should result in a safeguarding notification.  Both EMW and the GP were aware that Alex had a small bruise the chest, however neither of them made a safeguarding referral. 6.1.1 Recommendation 1 The LSCB should be assured that all professionals are aware of safeguarding guidance in relation to bruising in non-mobile babies and the possibility that non-accidental injury may be the cause.   All agencies should be aware of NICE guidance and must make a safeguarding referral where they see bruising in non-mobile babies. 6.2 FINDING 2 – Closure of CIN and Step Down to Early Help The process for step-down to Early Help was discussed with the family and they agreed to it.  However the decision to step down was not robust in a number of areas i.e. transfer of the case from one manager to another resulting in a different approach to step down (this took place without discussion between managers); limited multi-agency input into the final CIN meeting; a lack of rigour in ensuring that the family were supported during transition to Early Help services; a general lack of acknowledgement of the ongoing vulnerabilities and poor parenting capacity of both parents. 6.2.1 Recommendation 2(a) The LSCB should be assured that step down from CIN to Early Help is robust and that consideration be given to transitional arrangements where family continue to have specific vulnerabilities e.g. ongoing mental health issues; learning difficulties.  Parenting assessments should be required in these circumstances to support the decision to step-down.  24  6.2.2. Recommendation 2(b) CIN meetings should routinely be attended by Health Visitors where the child is under 12 months of age.  Where the child is older than 12 months an appropriate health professional should attend CIN meetings (e.g. School Nurse).  The lead professional should also attend CIN meetings if that is a different practitioner to those referred to here. 6.2.3. Recommendation 2(c)  The LSCB should be assured that CIN meetings are given priority by all professionals.  A quality assurance exercise of dip-sampling invitations to and attendance at CIN meetings would strengthen the baseline for strengthening agency participation. 6.2.4. Recommendation 2(d) The LSCB should explore with CSC and GPs a system to notify General Practice when a family is at CIN level. 6.3 FINDING 3 – Strengthening Focus on Fathers Little was known by professionals about father’s medical or social history.  Father is referred to by one professional as having learning difficulties, however there is no record of the source of this information.  There is also reference to father having had a difficult relationship with maternal grandmother in the past.  Father is considered in the pre-birth assessment but the review panel feels that the focus on father’s potential vulnerabilities and risk factors were not explored in sufficient detail. 6.3.1 Recommendation 3 The LSCB should be assured that all agencies take full account of the influence that fathers have on the family and ensure that any vulnerabilities or risk factors feature in assessments, referrals and interventions.         