Death of a 2-and-a-half-week-old boy in March 2016 due to a non-accidental head injury. Baby N was admitted to hospital having suffered a subdural haemorrhage and cardiac arrest. Police investigation commenced once post mortem indicated that Baby Ns death was suspicious. Prior to his death Baby N's sibling, Child A, a 21-month-old girl, had presented at hospital on two occasions with head injuries and was admitted on one occasion but child protection procedures were not commenced. Child A became the subject of care proceedings after police investigation. Crown Prosecution Service decided not to initiate a criminal prosecution in November 2018. Identifies issues relating to: information sharing; record keeping; compliance with child protection procedures; professional curiosity and the role of fathers. Mother is white European; father of Child A is black British/African; father of Baby N is black British/Caribbean. Learning includes: agencies need to ensure that they record full details of both the babys father and all members of the household; Children's Services need to ensure that they have understood medical information and not be entirely led by medical opinion; professionals in MASH need to discuss and evaluate information not just share it. Recommendations include: ensure the participation of agencies in serious case reviews, both in relation to attendance at meetings and responding to requests for information; findings of research into head injuries in children to be included in inter-agency training; seek assurances from partner agencies that managers are equipped with the skills and knowledge to provide effective oversight of child protection cases.
      
 Title:  Serious case review: Child A and Baby N. LSCB: Croydon Safeguarding Children Board Author: Steve Liddicott Date of publication: 2019  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.                                              CROYDON SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW  CHILD A AND BABY N   Author Steve Liddicott                                        January 2019             CSCB – SCR – Child A and Baby N Page 2 of 58 CONTENTS 1 Executive Summary ................................................................................................. 4 2 Introduction ............................................................................................................. 6 2.1 Decision to Initiate a Case Review .................................................................... 6 2.2 Notifications ...................................................................................................... 8 2.3 Decision to Undertake a Serious Case Review ................................................. 8 2.4 Methodology .................................................................................................... 9 2.5 Purpose Of A Serious Case Review ................................................................... 9 2.6 Conduct of the Serious Case Review .............................................................. 10 2.7 Terms of Reference. ....................................................................................... 10 2.8 Involvement of Staff ....................................................................................... 11 2.9 Involvement of Family Members .................................................................... 12 3 Methodology ......................................................................................................... 12 3.1 Timetable ........................................................................................................ 12 3.2 Medical Evidence ............................................................................................ 13 3.3 Chronologies and Independent Management Reviews ................................. 14 3.4 Format of the report ....................................................................................... 15 4 Context / Background ............................................................................................ 16 4.1 Genogram ....................................................................................................... 16 4.2 Table of Family Members ............................................................................... 17 4.3 Family History Prior To The Period Under Review ......................................... 17 5 Agencies Contact With The Family / Key Events ................................................... 18 5.1 Ante Natal Period to The Birth Of Child A ...................................................... 18 5.2 Birth Of Child A To First Hospital Attendance. ............................................... 19 5.3 Second Hospital Presentation ........................................................................ 25 5.4 Third Hospital Presentation ............................................................................ 27 5.5 Ante Natal Period To The Birth Of Baby N. ..................................................... 28 5.6 Hospital Admission And Death Of Baby N ...................................................... 28 6 Analysis of Professional Practice ........................................................................... 36 6.1 Children’s Social Care ..................................................................................... 36 6.1.1 Compliance with Policies And Procedures and Analysis of Practice. ............. 36 6.1.2 Management oversight and decision-making ................................................ 40 6.2 St George’s University Hospital NHS Foundation Trust (St George’s Hospital.)…………………………………………………………………………………………………………………..42 6.2.1 Compliance with Policies and Procedures and Analysis of Practice .............. 42 6.3 Croydon Health Service, Including Croydon University Hospital and Croydon Community Service Integrated Trust (The IMR also covers the Urgent Care Centre commissioned by Virgin Care Services) .............................................. 43 6.3.1 Compliance with Policies and Procedures and analysis of practice ............... 43 6.4 Guys and St Thomas NHS Trust, Evelina Children’s Hospital Paediatric Intensive Care Unit ......................................................................................... 46 6.4.1 Compliance with Policies and Procedures, and analysis of practice. ............. 46 6.5 General Practitioners ...................................................................................... 48 6.5.1 Compliance With Policies and Procedures and Analysis of Prcatice. ............. 48 6.6 Metropolitan Police Service, Specialist Crime Review Group. ....................... 50 6.6.1 Compliance with Policies and Procedures and Analysis of Practice .............. 50  CSCB – SCR – Child A and Baby N Page 3 of 58 7. Conclusions ........................................................................................................... 52 7.1 Comment ........................................................................................................ 52 7.2 Multi Agency ................................................................................................... 52 7.3 Record Keeping ............................................................................................... 54 7.4 Compliance with Child Protection Procedures ............................................... 55 7.5 Professional Curiosity ..................................................................................... 56 7.6 Research in relation to Head Injuries in Infants ............................................. 56 7.7 Conclusions ..................................................................................................... 57 7.8 Additional Recommendations ........................................................................ 58     CSCB – SCR – Child A and Baby N Page 4 of 58 1 Executive Summary 1.1 On 15th March 2016, Baby N, (at 2½ weeks old) was admitted to hospital in a critical condition having suffered a cardiac arrest. He was transferred to a specialist paediatric unit but sadly died on 21st March 2016. Baby N had suffered a subdural haemorrhage, where blood collects between the surface of the skull and the brain. His death was unexplained and therefore referred to the coroner who ordered a specialist post mortem. A police investigation commenced when the preliminary results of the post mortem indicated that the circumstances of Baby N’s death were suspicious.  1.2 Ms B is the mother of two children, Child A, aged 21 months at the time of Baby N’s death and Baby N. The children have different fathers: Mr D is the father of Child A and Mr C was the father of Baby N.  1.3 Ms B and Mr D’s relationship had ended by the time of Child A’s birth and they never lived together as a family. Ms B and Mr C were in a relationship at the time of Baby N’s death and lived in the same household together with both children.  1.4 Ms B is white, European having been born in Portugal. Her mother, Ms E, and brother, Mr F, were also resident in London during the period of time covered by this review. Mr D is black British / African and resides in the northwest. Mr C is black British / Caribbean and resides in London. Neither Ms B nor Mr D had previous involvement with children’s services although Mr C’s family had significant involvement with children’s services in Croydon.   1.5 Child A presented to hospital on two occasions with head injuries and was admitted on one occasion. Children’s Social Care in the London Borough of Croydon were notified of the admission, but this was not progressed beyond a contact to a referral.  Baby N was presented to hospital in an emergency, following cardiac arrest, although this was subsequently determined to be associated with a head injury.  Children’s Social Care were notified of the admission, but this was not progressed beyond a contact to a referral.   CSCB – SCR – Child A and Baby N Page 5 of 58   1.6 Child A was referred to children’s social care on 25th November 2014 having attended hospital with a suspected skull fracture and a large boggy swelling to the side of her head. Child A was 5 months old and pre-mobile, the explanation given did not fit the injury and in addition there had been a significant delay in seeking medical care. Despite these concerns, child protection procedures were not followed by children’s social care and the case was closed without a strategy meeting or an assessment.   1.7 Child A was taken to hospital with a further head injury on 22nd May 2015. On this occasion the injury was considered to be non-suspicious, and the case was not discussed with children’s social care, a consideration of the two injuries together should have prompted a referral.  1.8 On 15th March Baby N was admitted to hospital in a serious condition. He had suffered a cardiac arrest and an intracranial haemorrhage (bleeding between the skull and the brain). A referral was made to children’s social care indicating that non-accidental injury remained a possibility. Despite this, and the previous head injury to Child A, child protection procedures were again not followed. The case remained open as a contact and was closed following the death of Baby N, despite the cause of death being unknown.  1.9 No assessment took place until after the removal of Child A into police protection, following the results of a specialist post mortem indicating that the death of Baby N was non-accidental. A police investigation was then commenced into the death of Baby N and Child A’s first head injury. Child A then became the subject of care proceedings.  1.10 The conclusion of an expert report into the injury sustained by Child A in November 2014 concluded that she had suffered a fractured skull. The conclusion of the specialist post mortem in respect of Baby N was that he had also suffered a fractured skull as well as a fractured knee. Following a fact-finding hearing in the CSCB – SCR – Child A and Baby N Page 6 of 58 care proceedings1 in respect of Child A, the judge reached a conclusion about the probable cause of the injuries to the children.   The inquest in respect of the death of Baby N is yet to be held. The police investigation has concluded and the Crown Prosecution Service decided not to initiate a criminal prosecution in November 2018.  1.11 This case review has identified a number of issues relating to information sharing, record keeping, compliance with child protection procedures, professional curiosity and the role of fathers. In addition, there was a failure to recognise the significance of head injuries in pre-mobile children2 in some agencies.   2 Introduction  2.1 Decision to Initiate a Case Review 2.1.1 On 15th March 2016, Baby N, (2½ weeks old) was admitted to hospital in a critical condition having suffered a cardiac arrest. He was transferred to a specialist paediatric unit but sadly died on 21st March 2016. Baby N had suffered a subdural haemorrhage, where blood collects between the surface of the skull and the brain. His death was unexplained and therefore referred to the coroner who ordered a specialist post mortem. A police investigation commenced when the preliminary results of the post mortem indicated that the circumstances of Baby N’s death were suspicious.  2.1.2 Baby N was known to universal services. His older sister, Child A, had come to the attention of Children’s Social Care (CSC) in 2014 following her admission to hospital with a serious head injury.   2.1.3 On 3rd May 2016 Detective Inspector 1 (DI1), Croydon Child Abuse Investigation Team, referred the death of Baby N to the Croydon Safeguarding Children Board for consideration of the need for a Serious Case Review.                                                       1 The judge in the care proceedings made a finding “on the balance of probability” 2 Royal College of Paediatrics and Child Health report that 95% of severe head injuries that occur in the first year of life are inflicted CSCB – SCR – Child A and Baby N Page 7 of 58      2.1.4 On the 10th May, the Serious Case Review (SCR) sub group concluded that there were concerns about information sharing between agencies; whilst it was unlikely that additional information sharing would have changed the outcome for this child, there were concerns that there was learning from this case that should not be missed.  There appeared to be failings on the part of several agencies.   2.1.5 The SCR sub-group agreed that chronologies for Child A and Baby N would be requested from all relevant agencies, to inform a decision about the type of review to be commissioned. The case was further considered at the Serious Case Review sub group meeting on 12th July 2016.  2.1.6 A specialist post mortem in respect of Baby N had been undertaken on 12th April, the final results of which were not expected until September 2016. The initial findings of the post mortem had raised concerns that the death was suspicious.  2.1.7 In the light of this and in accordance with Working Together to Safeguard Children 2015 it was decided that a Learning Review, which could then be escalated to a Serious Case Review if necessary, should be undertaken by an independent reviewer.   2.1.8 Steve Liddicott was appointed as the independent lead reviewer. He is a social worker with considerable experience of the management of children’s social care services at a senior level, co-chair of the editorial board of the London Child Protection Procedures and experienced in chairing and contributing to Serious Case Reviews and Domestic Homicide Reviews.   2.1.9 The first Learning Review Panel meeting was held on 23rd August 2016 where draft terms of reference were discussed.  CSCB – SCR – Child A and Baby N Page 8 of 58 2.2 Notifications 2.2.1 On 14th April 2016 Ofsted were notified of the death of Baby N through the Serious Childcare Incident Procedure.   2.2.2 On 2nd August 2016 a summary was provided to the National Panel in relation to the decision to undertake a learning review. The National Panel responded on 15th September indicating their agreement with this approach.  2.2.3 On 2nd February 2017 the National Panel were informed of the decision to undertake a Serious Case Review and subsequently requested details of the findings of the post mortem. A response was sent on 14th February 2017 advising the panel that the post mortem indicated that Baby N died as a result of a traumatic head injury  2.3 Decision to Undertake a Serious Case Review 2.3.1 On 25th January 2017 the Learning Review Panel was advised that the specialist post mortem had concluded that the death of Baby N may have been unlawful and that a review of the head injury sustained by Child A had resulted in the police treating this as a crime. In the light of this new information the panel decided that the criteria for a Serious Case Review were now met under Section 5 "Abuse of a child is suspected, and that child has died". It was therefore decided to progress to a Serious Case Review and to appoint an independent person to chair the panel, Briony Ladbury.  2.3.2 Briony Ladbury is an independent safeguarding consultant and SCR Author.  She was previously the strategic lead for safeguarding children in NHS England (London Region) and NHS Member of the London Safeguarding Children Board.  She is currently the coordinator of the National Network for Designated Health Professionals and provided health representation for the Learning Into Practice Project (SCIE /NSPCC).    She continues to be a Trustee of the Victoria Climbie Foundation.  CSCB – SCR – Child A and Baby N Page 9 of 58 2.4 Methodology 2.4.1 It had been agreed that the Learning Review would be conducted in the same manner as a Serious Case Review (SCR), thus ensuring that if information emerged to confirm the suspicion of non-accidental injury the case could be escalated to a SCR. Therefore, whilst the overall timescale for the SCR has been longer than usual, the work undertaken on the LR was not wasted and contributed to the completion of the SCR.  2.5 Purpose Of A Serious Case Review3 2.5.1 The purpose of a Serious Case Review is to identify improvements and to consolidate good practice. Local Safeguarding Children Boards and their partner organisations should translate the findings from reviews into programmes of action that lead to sustainable improvements and the prevention of death, serious injury or harm to children. A SCR should be undertaken where:  Abuse or neglect of a child is known or suspected; and   Either the child had died; or  The child has been seriously harmed and there is cause for concern about the way in which the authority, their board partners or other relevant persons have worked together to safeguard the child.   2.5.2 SCRs and other case reviews should be conducted in a way which:   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   Makes use of relevant research and case evidence to inform the findings.                                                         3 Working Together, 2015, DfE CSCB – SCR – Child A and Baby N Page 10 of 58 2.6 Conduct of the Serious Case Review 2.6.1 Following the appointment of Briony Ladbury as the independent chair of the Serious Case Review the panel held its first meeting on 17th March 2017.  Steve Liddicott continued in his role as Independent Reviewer.    2.6.2 The timeframe of the review was agreed as the period from 1st January 2014 to 13th April 2016 and that the review would be conducted using a “hybrid model”. Chronologies would be requested from all agencies and following a review of the information Independent Management Reviews would be requested from relevant agencies. It was also agreed that a learning event would be held before the conclusion of the review to seek the views of practitioners.  2.6.6 It was the role of the lead reviewer to consider the chronologies and IMRs, provide feedback to the panel as regards their quality and raise any further queries which would assist the review.   2.7 Terms of Reference. 2.7.1 The following terms of reference were agreed by the panel: a) What were the key relevant points / opportunities for decision making, visits and assessments in this case in relation to the children and family?  b) Were meetings, assessments and planning, timely and were decisions reached in an informed and professional way? In particular the i. response to the first hospital presentation of the oldest child with a significant head injury at under 6 months of age,  ii. response to the second hospital presentation of the same child   iii. response to the emergency call and admission to hospital iv. response following the death of baby N   c) Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of CSCB – SCR – Child A and Baby N Page 11 of 58 abuse or neglect and about what to do if they had concerns about a child’s welfare?  d) Was there sufficient knowledge / involvement / engagement of the fathers of the children?   e) Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  f) Did actions accord with the information that was or could have been available? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments?  g) Were there any issues, in communication, information sharing or service delivery, between workers/agencies?  h) Were senior managers or other organisations and professionals involved at points in the case where they should have been?  i) Were there organisational difficulties being experienced within or between agencies? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  j) Was there sufficient management accountability for decision making?  2.8 Involvement of Staff 2.8.1 A learning event was undertaken in October 2017. Those staff still employed within partner agencies and / or representatives of those agencies were invited to read a summary of this report and discuss the learning points identified. The learning event was led by the panel chair and the independent reviewer; other members of the SCR Panel were also in attendance. The insights on practice CSCB – SCR – Child A and Baby N Page 12 of 58 and procedure that emerged during the course of the learning event have been incorporated into this report.     2.9 Involvement of Family Members 2.9.1 The parents of both children were informed that a serious case review was being undertaken. However, because of the police investigations into the death of Baby N and the injury to Child A, and the care proceedings in respect of Child A, they did not respond to the offer to participate during the period that this review was being undertaken.   2.9.2  However, following the conclusion of the care proceedings and the police investigation, the parents were again offered an opportunity to meet with the lead reviewer.  Mr D, Child A’s father has seen and commented on this report.  He was party to the care proceedings and therefore had heard the evidence provided to the court in respect of the injuries to his daughter and to Baby N.  His factual corrections have been incorporated into the report.  His primary concern was about the publication of the report and the potential invasion of his privacy.  2.9.3  Baby N’s father was given the opportunity to participate in the review.  A range of dates were offered to him, at his request, but ultimately he did not attend.     2.9.4 The children’s mother declined the opportunity to take part.  Again she was offered further opportunity but confirmed that she did not wish to participate in the Serious Case review. 3 Methodology 3.1 Timetable   Referral made to Serious Case Review Sub Group 10 May 2016  Serious Case Review Sub Group decided to commission a Learning Review 12th July 2016  Learning Review Panel met 24th August 2016  Learning Review Panel met 28th October 2016  Learning Review Panel met 9th November 2016 CSCB – SCR – Child A and Baby N Page 13 of 58  Learning Review Panel met 25th January 2017  Serious Case Review Panel met 17th March 2017  Serious Case Review Panel met 26th May 2017  Serious Case Review Panel met 22nd September 2017  Learning Event 20th October 2017  Serious Case Review Panel met 17th November 2017  Serious Case Review Sub Group met 20th March 2018  Croydon Safeguarding Board received the final report 27th March 2018  3.2 Medical Evidence 3.2.1 Baby N was admitted to hospital on 16th March 2016, having suffered an intracranial haemorrhage; he remained in a critical condition until his death on 21st March 2016. At the time of his death the view of Safeguarding Doctor 1 (SGDR1) was that non-accidental injury was a possibility although at that point there was no corroborating evidence. The cause of the intracranial haemorrhage was at that point unexplained. As an unexplained death the case was referred by Evelina Children’s Hospital to the Coroner who requested a specialist post mortem, which took place on 12th April 2016.  3.2.2 Although the full results of the specialist post mortem were not due until September 2016, the initial findings raised concerns that the death of Baby N was suspicious.  3.2.3 The Serious Case Review sub group were made aware of these initial concerns at the meeting of 10 May 2016.  On 12th July 2016 the decision was made to proceed with a Learning Review pending the outcome of the post mortem.  3.2.4 The meeting of 25th January 2017 considered the initial findings of the special post mortem as reported by DI1 who had been in attendance. The findings indicated a number of injuries with no organic cause for the baby’s death. In addition, further information had emerged in relation to the first hospital presentation of Child A with a head injury, which was now being treated as non-accidental. It was on this basis that the decision was made to move to a Serious Case Review.  CSCB – SCR – Child A and Baby N Page 14 of 58      3.2.5 The post mortem listed the following injuries to Baby N:  Metaphyseal (bucket) fracture on the lower left femur  Axonal brain injury  Subdural haemorrhaging to the brain and spinal cord   Sub-scalp bruising   The cause of death was found to be a head injury.  3.2.6 A further update was provided to the Serious Case Review Panel meeting of 17th March 2017 which indicated that medical reports so far stated that there were no predisposing health conditions or abnormalities in respect of Child A’s skull fracture, which was either caused by an accidental or non-accidental injury that was yet to be disclosed.  3.2.7 Specialist medical reports were commissioned during the course of care proceedings in respect of Child A, the conclusions of which were made known to the Case Review Panel. A fact finding hearing took place in October 2017, the outcome of which was also made known to the Panel.  3.2.8 Baby N’s injuries were non-accidental in relation to the fracture to his knee as well as head injuries. There were also no predisposing health conditions or abnormalities in relation to his injuries.  3.3 Chronologies and Independent Management Reviews 3.3.1 Chronologies and Independent Management Reviews were requested and received from the following agencies.  Croydon CCG (including GPs for each parent and child) – GPs 1 to 3  Croydon Health Services (including Croydon University Hospital, Health Visitors and School Nurses and Family Nurse Partnership)  Metropolitan Police - Police  Croydon Children’s Social Care  St George’s Hospital – (midwifery) CSCB – SCR – Child A and Baby N Page 15 of 58  Evelina Children’s Hospital  London Ambulance Service (chronology only)  3.3.2 Agencies were also asked to provide a summary of any other relevant information outside of this timeframe.  3.4 Format of the report 3.4.1 The remainder of this report is structured as follows:  Section 4 provides details of family members and the family history prior to the period under review.  Section 5 provides a chronological record of events that took place between 1st January 2014 and 14th April 2016.  Section 6 provides an analysis of professional practice by agency between 1st January 014 and 14th April 2016 and includes learning points and agency recommendations.  Section 7 sets out the conclusions and additional recommendations for CSCB.  3.4.2 Chronologies and management reviews were not always submitted in a timely manner during the course of this review and it was necessary to seek further clarification from some agencies. In addition, instructions provided in respect of the identification of key staff were not followed consistently making it difficult to cross-reference between agency contributions. Whilst care has been taken to ensure that the actions of staff have been correctly attributed, it has not been possible to devise an accurate anonymisation grid.   3.4.3 At the end of most sections of this report, there are boxes summarising the key learning points arising out of that section, along with the relevant agency recommendations.          CSCB – SCR – Child A and Baby N Page 16 of 58   4 Context / Background 4.1 Genogram                         1978Mr D401989Ms B292014ChildA41984Mr C342016 - 2016BabyN24d1959Ms E591996Mr F22198731???CSCB – SCR – Child A and Baby N Page 17 of 58    4.2 Table of Family Members  Name Age at time of incident (March 2016) Gender Ethnicity Relationship to Child A / Baby N  Baby N 2½ weeks M Mixed Parentage White European and Black Caribbean Child A’s Half Brother Child A 22 months F Mixed Parentage White European and Black African  Baby N’s Half Sister Ms B 26 years F White European Portuguese Child A / Baby N’s Mother Mr C 31 years M Black Caribbean British Baby N’s Father Mr D 38 years M Black African British Child A’s Father Ms E 57 years F White European Portuguese Child A / Baby N’s Maternal Grandmother Mr F 21 years M White European Portuguese Child A / Baby N’s Maternal Uncle  4.3 Family History Prior To The Period Under Review 4.3.1 Ms B is the mother of two children Child A   and Baby N. The father of Child A is Mr D; the father of Baby N is Mr C. At the time of Baby N’s death Ms B and Mr C were living in the same household.  4.3.2 Agency records submitted for the purposes of the case review contain very little background information about Ms B or Mr D. However, during the course of the case review, the following background information was shared in respect of Mr C:  Mr C’s family were well known to Croydon Children’s Social Care, the family history included violence, criminal activity, CSCB – SCR – Child A and Baby N Page 18 of 58 neglect and alcohol abuse. It is clear from the information held by Croydon Children’s Social Care that Mr C had an emotionally and physically deprived childhood.   Mr C is known to the Police but does not have a criminal record. He had 2 children with a previous partner who had made allegations of DV.   It is of note that although Croydon Children’s Social Care held extensive information in relation to Mr C and his family having been involved with them over many years, none of this information was accessed during the period under review.   Learning Points  Croydon Children’s Social Care held extensive information about Mr C and his family, which was not accessed during the period under review. He had a troubled and deprived childhood, factors which should have alerted agencies to potential risks and vulnerabilities.  5 Agencies Contact With The Family / Key Events 5.1 Ante Natal Period to The Birth Of Child A 5.1.1 Ms B attended St George’s Hospital for ante natal care, the first recorded contact being on 14th November 2013 when she self-referred for a booking appointment in respect of her pregnancy. The booking appointment took place on 7th December, Ms B told MW1 that the pregnancy was unplanned and the baby’s father had sickle cell trait. She also stated that she was suffering from an infection and depression.   5.1.2 The history of depression was not explored further by the midwife. Details of the baby’s father and whether he and Ms B were still in a relationship were not discussed   5.1.3 As is routine, Ms B was asked about domestic violence and answered in the negative. She named two people as her birth companions, one was her mother Ms E the other name given was the first name of Mr D, suggesting that they were still in a relationship.  5.1.4 In February 2014 Ms B was treated for an infection; it is not clear if this was the same infection as mentioned in November 2013. CSCB – SCR – Child A and Baby N Page 19 of 58   5.1.5 On 4th April 2014 MW2 referred Ms B to the specialist Mental Health Midwife as she had been experiencing anxiety attacks for which she had already been seen by her GP. An appointment was offered for the 8th May which Ms B did not attend. This was followed up by MW4 at the next antenatal appointment. She recorded that she had spoken to Ms B who had said that she was no longer having panic attacks, she had spoken to her GP and found his advice useful. Ms B stated that she no longer wanted to see the mental health midwife, as she felt well and happy.  5.1.6 Child A was born on 1st June 2014 after an uneventful labour, MW5 recorded that Ms B was accompanied by her mother.  Ms B and child A were discharged from hospital on 4th June, hospital notes recorded an uneventful post-natal stay.  Learning Points  Agencies need to ensure that they record full details of both the baby’s father and all members of the household.  5.2 Birth Of Child A To First Hospital Attendance. 5.2.1 Child A received universal Health Visitor services throughout this period; she appears to have been developing normally and no concerns were noted. The only other adult mentioned in recordings is Ms B’s mother Ms E.  5.2.2 Child A was also registered with a general practitioner (GP1); again no concerns were noted.  5.2.3 On 4th November 2014, Child A’s father, Mr D was arrested by Greater Manchester Police and charged with assaulting a woman during an argument. Mr D received a caution for this offence. The identity of the woman was not recorded; Mr D advised that it was not Ms B.      CSCB – SCR – Child A and Baby N Page 20 of 58  5.2.4 On the 25th November 2014, Child A, aged five months, was taken to the Emergency Department at Croydon University Hospital with a large “boggy swelling” to the left side of her head. Ms B reported that the injury had occurred on 22nd November whilst Child A was in the care of her 18yr old uncle Mr F. It was reported that Child A had been propped in a sitting position, had fallen over and hit the right side of her head on a wardrobe  5.2.5 Ms B had become concerned that the swelling was getting larger so had brought Child A to the hospital. She also reported that 6 weeks previously the baby had rolled off the bed and hit the right side of her head but she did not wake up and there was no sign of injury. Child A was admitted to the children’s ward for further investigations.   5.2.6 On the evening of 25th November the Pediatrician 1 (P1) telephoned Croydon Children’s Social Care out of hours service to report a suspicious injury to Child A and request that agency checks be carried out. He stated that they were not sure if the injury was non accidental and that Child A was to be admitted for further investigations.  5.2.7 On the morning of 26th November P1 telephoned Croydon Children’s Social Care MASH with a further update, he stated that a CT scan had been carried out, which indicated that there was an extracranial haematoma associated with a possible short non displaced parietal (skull) fracture, no other injuries or bruises had been observed and a full skeletal survey was planned for later in the day.  5.2.8 As recorded by Croydon Children’s Social Care the concerns expressed during this this telephone call were followed by a written referral. The factors highlighted were that Ms B had stated that the child had hit the right side of her head whilst the injury was to the left side; the fact that the child was in the care of her 18yr old maternal uncle; the 3  day delay in seeking medical attention from Saturday to Tuesday. Croydon Children’s Social Care confirmed that the family was not known to them. The CSCB – SCR – Child A and Baby N Page 21 of 58 written referral made reference to the possibility that the injury was not accidental.   5.2.9 The referral to Croydon Children’s Social Care was clear, appropriate and in line with the London Child Protection Procedures.  5.2.10  The Social Worker 1 (SW1) discussed the contact with her manager Croydon Children’s Social Care M1 during which it was agreed that any escalation of the case beyond a contact would be dependent on the outcome of medical tests and information received from other agencies. The London Child Protection Procedures say that a decision on whether or not to move to a S47 or an assessment should be made within 24 hours. These timescales were not adhered to.  5.2.11  On 27 November 2014 a request for information was sent by e-mail to the police officer in the Multi Agency Safeguarding Hub (MASH). Police Constable 1 (PC1) completed research on the family as requested. This was risk assessed by the police MASH nominated decision maker, allocated a RAG rating of Amber / Level 3 and sent back the same day to the Croydon Children’s Social Care MASH Manager 1 (Croydon Children’s Social Care M1) for risk assessment and a decision on any further action required. Ms B was contacted for her permission and agency checks were carried out which indicated no prior concerns. It has been impossible to determine whether or not actions were taken according to the then MASH protocol.   5.2.12  On the same date P1 reported to CSC 1 that a full skeletal x-ray had been carried out which had found no other injuries and no skull fracture. Ms B was reported as being appropriate and attentive to Child A and as having been present throughout her hospital stay.  5.2.13  Child A was said to be medically fit for discharge and Croydon University Hospital were recorded as awaiting a response from Croydon Children’s Social Care before discharging her home.   CSCB – SCR – Child A and Baby N Page 22 of 58   5.2.14  Case recording by both Croydon Children’s Social Care and Croydon University Hospital is unclear as to what, if any, response was made by Croydon Children’s Social Care; the Hospital records noted that Croydon Children’s Social Care would arrange further contact and follow up.  5.2.15  Case recording by Croydon Children’s Social Care is poor and does not record the response to Croydon University Hospital. There is also no record that the outcome of the referral was fed back. Croydon Children’s Social Care had decided that despite the outstanding concerns in relation to the explanation of the injury the case would not progress to an assessment. There is no information as to how or why this decision was made.  5.2.16  It is of concern that this injury was not assessed by Croydon Children’s Social Care as reaching the threshold for intervention. It clearly fulfills the criteria within the London Procedures of a suspicious injury to a pre-mobile child and should have been treated as a child protection referral and triggered a strategy discussion with police and other agencies. The referral was not discussed with the police at the time; indeed they remained unaware of this incident until after the death of Baby N.   5.2.17  The response from Croydon Children’s Social Care was to refer the case to the Health Visiting Service for follow up. The Croydon Children’s Social Care M1 did not action this until 12 December, noting that there had been no health professional in the MASH for a week.  A written referral to the Health Visiting Service was not made until 16th December, and there was no attempt to contact the HV by phone.  5.2.18  The request appears to have simply asked the Health Visitor to consider doing a follow up visit and refer any concerns back to Croydon Children’s Social Care. It is unclear why, at the very least there was no direct discussion with the health visiting service. In effect this meant that there was a delay of seven weeks between the admission of Child A to hospital and her been seen by any other professional. CSCB – SCR – Child A and Baby N Page 23 of 58  5.2.19  Croydon Children’s Social Care then closed the case. The manager’s decision record dated 11th December and completed by Croydon Children’s Social Care M1 states that: “At present SC will not undertake an assessment however we will request that a health visiting team undertake a follow-up visit – discuss incident further, welfare check of home environment and presentation of adults in household and considering general care of Child A…’. This decision was taken despite the fact that Croydon Children’s Social Care received a police report on 7th December indicating conflict between the parents. The manager’s decision concerning the level of need is recorded as Level 2 Green. There is no record of why the level of risk was reduced from Amber to green other than that agency checks had raised no concerns.  5.2.20 There is no information as to the rational for this course of action, this was a serious injury to a pre-mobile child, and as such it was inappropriate to ask the HV to, in effect, assess the child’s welfare. It is also unclear why the request was sent by letter without any prior discussion.   5.2.21  As a response to a child protection referral this was totally inadequate and not in accordance with procedures. The response would suggest that the child protection nature of the referral was not recognised and that having been told that Child A did not have a skull fracture Croydon Children’s Social Care failed to take into account a number of indicators of risk; i.e. the apparent serious nature of the injury4, the age of the child, the inconsistent explanation for the injury and the delay in presentation.  5.2.22   HV1 received notification from Croydon University Hospital in relation to Child A’s admission, she made attempts both by phone and letter to contact Ms B. Eventually a home visit was arranged for 14th January 2015. The referral from Croydon Children’s Social Care was received on 29th December 2014.                                                         4 It is not unusual for the interpretation of x-rays to differ. In this instance, a subsequent “expert opinion” confirmed that there had been a facture. CSCB – SCR – Child A and Baby N Page 24 of 58  5.2.22  The case was triaged by the MASH health professional on the 26th November 2014. There is no record of any further discussion within the MASH team or with health management. There was also no discussion between HV1 and the MASH health professional or Croydon Children’s Social Care.  5.2.23  It is not clear whether the information that HV1 would not be seeing the child until January was shared through the MASH process.  5.2.24  HV1 carried out the planned home visit on 14th January, there were no concerns arising from this visit, this information was fed back to Croydon Children’s Social Care on 22nd January 2015.   Learning Points  There is a need for all agencies to record information in relation to the fathers of children, family relationships and details of all adults within the household.  No agency checks were undertaken in relation to Mr D  Croydon Children’s Social Care did not follow Child Protection Procedures or demonstrate an awareness of indicators of abuse – they decided not to escalate the case but to wait for more medical information. SW decision making should not be led by medical opinion.  It is unclear how the decision to discharge Child A from hospital was made.  The outcome of the referral to Croydon Children’s Social Care should have been fed back to the hospital.  There needs to be clarity in the use of terminology, i.e. “child protection referral” v “contact”  Police should have been informed of the injury to Child A.  Professionals in MASH need to discuss and evaluate information not just share it.      CSCB – SCR – Child A and Baby N Page 25 of 58 5.3 Second Hospital Presentation 5.3.1 Between the first and second hospital presentations there were no significant contacts with health services, and no contact with Croydon Children’s Social Care. Ms B did however have some contacts with the police, the most significant of which related to disputes with Mr D in relation to Child A.  5.3.2 On 6th December 2014 Ms B contacted the police saying that Mr D was threatening to take Child A to Nigeria, she was advised to keep the child’s passport away from him and to seek legal advice. Ms B also stated that the previous August she had been assaulted by her ex-partner, however, she refused to confirm her ex partner’s identity so no further action was taken. A police notification was sent to Croydon Children’s Social Care on 7th December 2014.  Mr D denies that either event occurred.   5.3.3 On 12th December 2014 Ms B made an allegation of assault to the Transport Police. She stated that she had arranged to meet Mr D to discuss arrangements with regard to Child A, and that he had grabbed her wrist causing reddening. Mr D was arrested but Ms B’s allegation was not supported by CCTV evidence which showed her causing reddening to her own wrist, no further action was taken.  5.3.4 On 22nd May 2015 Child A was seen the Urgent Care Centre at Croydon University Hospital. The hospital notes indicate that she had a bruise on her cheek and swelling around the right eye. Child A was at this point 11 months old. The explanation given was remarkably similar to that given at the first hospital presentation in that she was said to have rolled off the sofa and hit the right side of her head on a coffee table. Ms B also gave a history of jumping. At the point of the first hospital presentation Child A was pre-mobile; at the age of 11 months she would have begun to mobilise although it is not known how mobile she was at that time. This second presentation appears to have been assessed in isolation from the earlier injury. The fact that Child A had suffered two head injuries within the first year of her life should have triggered concerns.   CSCB – SCR – Child A and Baby N Page 26 of 58  5.3.5 It was recorded that Child A was brought to the hospital by her parents. Since Ms B and Mr D were not in a relationship and had not lived together in London, the male was unlikely to have been Child A’s father. Since the identity of the man is not recorded, it is likely that this was an assumption rather than information that was checked.  5.3.6 Although Urgent Care Centre and Croydon University hospital are different providers they access the same IT services so that information is shared. Information about the previous injury to Child A was available to the staff dealing with Child A5. The records note that safeguarding was considered but on assessment no safeguarding concerns were identified.   5.3.7  There is nothing to indicate the basis for this decision or whether the injury was fully considered in the light of the previous presentation, nor is there any information as to whether any Health Safeguarding professionals were consulted.  The fact that Child A had suffered two head injuries during the first year of her life should have triggered concerns and led to further exploration.   5.3.8 There was no contact with Croydon Children’s Social Care in relation to this injury which seems to have been viewed in isolation. Given the previous head injury to Child A and the concerns of the hospital in relation to possible non accidental injury, it is surprising that they did not contact Croydon Children’s Social Care to ascertain the outcome of the previous referral and inform them of the second injury to this child who was still under a year old. The hospital records clearly indicated the understanding of Croydon University Hospital that Croydon Children’s Social Care were going to follow up the previous injury.                                                            5 During the course of the practitioners’ event, staff from Croydon University Hospital pointed out that the reason for the previous presentation, i.e. a head injury, would have been recorded on the patient record used by the examining doctor. CSCB – SCR – Child A and Baby N Page 27 of 58 5.3.9 Information about the attendance at Croydon University Hospital was passed to HV1 and GP1. HV1 attempted to contact Ms B by telephone without success. Child A should have been due for her one-year review around this time but this did not take place. The incident took place during a period when one-year reviews were not being carried out routinely due to capacity issues.  5.3.10 Taking the two hospital presentations together it would have been good practice for HV1 to prioritise a targeted review and to discuss the case in child protection supervision and with the safeguarding team.  Learning Points  The patient record card recorded that Child A had previously been seen with a head injury. The hospital records should have been checked in relation to that previous injury to Child A  The two injuries together should have triggered further investigation and discussion with safeguarding professionals within the hospital.  Children’s Services Croydon Children’s Social Care should have been contacted in relation to this injury.  There is a need to record the identity of all adults who accompany a child to hospital.  Given the two hospital presentations with head injuries it would have been good practice for the HV to prioritise a targeted one-year health review.  5.4 Third Hospital Presentation 5.4.1 On 10th and 13th July Ms B took Child A to see GP1.  GP1 diagnosed acute conjunctivitis and prescribed medication. On 20th July she attended St George’s Hospital with “red eyes”, the diagnosis was probable allergic conjunctivitis and she was discharged home with advice to follow up with the GP.  5.4.2 There is no further information regarding this hospital presentation or why Ms B took Child A to St George’s Hospital instead of her local Croydon University Hospital.  CSCB – SCR – Child A and Baby N Page 28 of 58 5.5 Ante Natal Period To The Birth Of Baby N. 5.5.1 On 1st August 2015, Ms B self-referred to St George’s Hospital for antenatal care. She stated that Mr C was her boyfriend and next of kin and gave a separate address for him.  5.5.2 On 9th August she attended for a booking appointment and disclosed current depression for which she was not having any treatment. There is no record of this being followed up. She was asked about domestic violence and responded in the negative.  5.5.3 The pregnancy was uneventful, Ms B attended for a planned induction in late February and Baby N was delivered the next day with no complications. Ms B’s birth plan stated that Mr C was to be present at the birth as was her mother; the hospital records do not say who was actually present at the birth although it is recorded that Mr C was present on the ward. Ms B and Baby N were discharged the day after his birth, no concerns were noted.  5.6 Hospital Admission And Death Of Baby N 5.6.1 Baby N was seen at home by the Community Midwife (MW2) on 2nd March 2016, he was slightly jaundiced but no concerns were noted. He was seen again on 9th March, again no concerns were noted and he was discharged to the care of the HV service.  5.6.2 On 10th March 2016 HV2 completed a planned new birth visit, Baby N was developing normally, Ms B was reported as appropriate ‘in her interactions with the baby. Ms B reported that she was receiving support from Mr C and her extended family. Child A was also seen during this visit.  No concerns were reported by HV2 and she recommended universal Health Visiting Services.  5.6.3 On 15th March 2016 the London Ambulance Service were called to the home address as Baby N had stopped breathing. On arrival, Baby N was lying on a couch visibly cyanosed (having a bluish discoloration of the skin, fingernails, and mucous membranes caused by a deficiency of oxygen in the blood) and not breathing. Ambulance Staff tried to resuscitate him by giving cardiopulmonary resuscitation (CPR).  CSCB – SCR – Child A and Baby N Page 29 of 58 5.6.4 The account given by the parents to the Ambulance staff was that Baby N had been fed and winded prior to vomiting and going limp in his father’s arms. Police were also called to the home address to deliver a defibrillator.  5.6.5 Baby N was conveyed to Croydon University Hospital as an emergency. The police officers who had attended the home address accompanied Ms B to Croydon University Hospital, they spoke to Ms B and Mr C and also to the hospital staff.  The information from the medical assessment at this time was that the incident was not thought to be suspicious.  There was no further police action or involvement until after the death of Baby N.  5.6.6 The hospital reported that Baby N was admitted with no heart beat; following resuscitation he was transferred to the Paediatric Intensive Care Unit in Evelina Children’s Hospital.  5.6.7 Following notification of the admission of Baby N to Croydon University Hospital, a Croydon Children’s Social Care MASH SW telephoned Croydon University Hospital and spoke to the ward sister who informed her that the cardiac arrest was thought to be caused by some neurological dysfunction. The hospital records relating to discussions during this short admission are sparse. Whilst it is noted that there was a discussion with Croydon Children’s Social Care the contents of the exchange are not recorded.   5.6.8 On admission to Evelina Children’s Hospital a CT scan was undertaken which showed evidence of an acute extra axial bleed (bleeding that occurs between the skull and the brain for which trauma is the most common reason).  The initial history given by the parents was that Baby N had been noted to have jerky movements during sleep since birth. He had had a cold and cough with minor fever for two days prior to the incident.  He was reported to have had two to three episodes of vomiting during the evening and had been found floppy and not breathing by his father after vomiting. The parents’ account stated that CPR was provided, although the ambulance staff reported that no active CPR was being performed when they attended CSCB – SCR – Child A and Baby N Page 30 of 58  5.6.9 Evelina Children’s Hospital took a full family and social history, which was good practice. A number of investigations were planned and undertaken by Evelina Children’s Hospital to try and determine the cause of Baby N’s presentation, and the subdural haematoma.  5.6.10  PICU Dr2 asked the parents for further information: they reported that Baby N had had difficulty with feeding from birth and described him as colicky. They said that HV2 had been due to visit on the Monday but had not telephoned or visited. The Health Visiting service have no record of any visit being arranged for that date.  5.6.11  PICU Dr 2 reviewed events with the parents who stated that Mr C had returned from work at 10pm, Ms B breastfed Baby N at 11pm and gave him a top up formula feed as he appeared hungry. The baby continued crying so Mr C took him into the kitchen to allow Ms B to get some sleep. Baby N vomited and Mr C then took him back to the bedroom and placed him in his cot. A few minutes later he heard choking noises and found Baby N floppy and unresponsive.  The family denied any trauma or dropping the baby. Ms B reported concerns about myoclonic jerks since birth (involuntary movements which happen naturally during sleep).  5.6.12  The parents provided three different accounts of the events leading up to them calling the emergency services. Subsequently, they provided a fourth version of events to an expert commissioned in the care proceedings. Baby N was initially reported to be in his father’s arms, later found by his father in his cot and in the final version, found by his mother. Whilst it is understandable that these discrepancies were not noticed at the time, when the focus was on treating Baby N, they may have provided an early indication of the need to consider carefully the circumstances leading up to Baby N’s admission to hospital.     5.6.13  On the 17th March, Safeguarding Nurse 1 (SGN1) at Evelina Children’s Hospital completed a safeguarding pro forma and CSCB – SCR – Child A and Baby N Page 31 of 58 contacted both Health Visiting and Midwifery services for further information about the family and the birth of Baby N. This was good practice.  5.6.14  SGN1 also contacted the MASH in Croydon Children’s Social Care to discuss the baby’s   admission. She informed SW4 that there was as yet no definitive diagnosis and that investigations were continuing. Organic causes were being considered alongside the possibility of non-accidental injury. The conversation was followed up by an electronic referral in line with procedures. SW4 informed SGN1 that the family had previously been referred to CSC in 2014 in relation to a head injury to Child A.  5.6.15  Despite the fact that the referral clearly stated that non accidental injury was a possibility Croydon Children’s Social Care opened a contact which they did not progress to referral, there is no explanation as to why this course of action was followed. Timescales were again not adhered to. In line with Child Protection Procedures, a strategy meeting should have been convened and consideration given to a child protection investigation within 24 hrs.  5.6.16  No checks were undertaken on Mr C; he had not been included in the agency checks undertaken in 2014 as he was not in a relationship with Ms B at that point. Checks in 2014 included the maternal family only.  5.6.17  During the period between the admission of Baby N and his death, Croydon Children’s Social Care maintained telephone contact only. Decision making was led entirely by medical opinion and there is no evidence of any consideration being given as to the welfare of Child A.  No contact was made with the police and no strategy discussion was held.  5.6.18  Given the possibility that this was a non-accidental injury and the fact that there had been a previous injury to Child A, a strategy discussion should have been held following the referral from Evelina Children’s Hospital.   CSCB – SCR – Child A and Baby N Page 32 of 58   5.6.19 On 18th March 2016 an email was received from Safeguarding Nurse 2 (SGN2)  summarising the opinion of  SGDR1 that non accidental injury remained a possibility, The email stated that Baby N had suffered an unexplained bilateral subdural haematoma. The factors that made a diagnosis of non-accidental injury more likely were the nature of the injury. Factors making a diagnosis of non-accidental injury less likely were the lack of bruising or significant signs of external injury, no retinal damage, skull fracture or rib fractures. The parent’s story was said to be consistent (although see above, 5.6.12) and their interaction normal. No other known risk factors for non-accidental injury were identified. SGDR1 concluded that non-accidental injury remained a possibility but at that point there was no corroborative supporting evidence. He stated that it was not possible to ascribe a cause to the intracranial haemorrhage at present. There was no response from Croydon Children’s Social Care to this email.  5.6.20  It is recorded that SW4 and her manager Croydon Children’s Social Care M2 wanted to progress the case in order that it would remain open pending further medical information. This was not agreed by the manager of the receiving team Croydon Children’s Social Care M4 and was then escalated to a more senior manager, Croydon Children’s Social Care M3 for a decision.  5.6.21  Baby N died on 21st March 2016. On the same day, and despite the email of 18th March Croydon Children’s Social Care M3 decided not to progress the case to an assessment. This was not in line with Child Protection Procedures. This was a suspicious death of a baby, a second point which should have triggered a strategy discussion and a child protection investigation.  5.6.22 As an unexplained death the case was referred to the coroner’s office. The Coroner’s office referred the death to the police on 22nd March 2016, as an unexplained death it required a police investigation.   CSCB – SCR – Child A and Baby N Page 33 of 58    5.6.23  There are differences between agencies in their accounts of the information given by Evelina Children’s Hospital in relation to Baby N’s presentation and eventual death. However, Evelina Children’s Hospital were clear that the cause of death was unknown and the reason for the cardiac arrest was unexplained.  5.6.24 This was the information relayed to Croydon Children’s Social Care, however despite the email received on 18th March 2016 stating that non-accidental injury remained a possibility, and being clearly informed that the cause of death was unknown, Croydon Children’s Social Care seem to have formed the belief that Evelina Children’s Hospital were of the opinion that the death was not suspicious. There is no record of how or why they came to this definitive conclusion.  5.6.25 The IMR completed by Croydon Children’s Social Care states that: “The skeletal survey carried out after Baby N’s death identified a fracture to the knee, this did not alter the medical opinion of Evelina Children’s Hospital, concluding this was unlikely to be non-accidental, but as a result of the intensive CPR when Baby N had his cardiac arrest.” The author has requested further information from Croydon Children’s Social Care as to the origin of this statement, however none has been forthcoming. There is no information in either the records of Evelina Children’s Hospital or those of Croydon Children’s Social Care to support this assertion.   5.6.26 Following the death of Baby N, Detective Sergeant 1 (DS1) contacted Croydon Children’s Social Care and was told by SW4 that they had been made aware of Baby N the previous week but that it had not been suspicious and Croydon Children’s Social Care had been guided by medical evidence. An email sent to the police provided information about the hospital admission but omitted to say that there was a possibility of non-accidental injury and attributed the cerebral bleed to repeated CPR. The existence of Child A and the previous head injury were not mentioned. CSCB – SCR – Child A and Baby N Page 34 of 58     5.6.27  The police commenced an investigation, led by DI1. It is of note that in the police record of the decision not to treat the referral as a fast time response it states that “Doctors have indicated that there is nothing suspicious” It would appear the police decision making was based on incomplete information supplied by CSC.   5.6.28  The death summary compiled on 21st March 2016 by Consultant PICU DR3 at Evelina Hospital states under the heading Safeguarding: “Safeguarding team involved in view of subdural bleeds and unexplained cause for cardio-respiratory arrest.” The cause of death is clearly given as unknown.  5.6.29  The information in the death summary does not support the repeated assertions from other agencies in particular Croydon Children’s Social Care that the death was not suspicious.   5.6.30   Whilst the Rapid Response process was initiated, there was not a rapid response meeting held following the death of Baby N. The notification of the decision not to hold a rapid response meeting is flawed in that it says that there were no safeguarding concerns, fails to acknowledge that non-accidental injury was considered to be a possibility and incorrectly states that when Croydon University Hospital assessed Child A in 2014, they did not raise any safeguarding concerns when in fact they made a safeguarding referral.   5.6.31  It would appear that the reason why a rapid response meeting was not held was that Baby N’s death was not considered to be unexpected. An expected death is defined as “the death of a child not anticipated as a significant possibility 24 hours before the death”6. He had been in hospital from the 16th March until he died on the 21st March. It was the view of some of the professionals attending the learning event and the author of this                                                       6 Croydon Rapid Response Meeting Terms of Reference CSCB – SCR – Child A and Baby N Page 35 of 58 report that this was a missed opportunity to explore the circumstances of Baby N’s death at an early stage.    5.6.32  This was a sudden and unexpected death of a baby. Had a rapid response meeting been held it would have facilitated the sharing of information between agencies and ensured that complete and up to date information was shared? It would also have provided an opportunity to correct any inaccuracies.  5.6.33  DI1 consulted with senior managers and it was agreed that she would visit the family home, speak to both parents and await the outcome of the post mortem before making any further decisions. The home visit took place on 24th March. On 9th April DI1 was informed by the senior coroner that as Baby N had suffered subdural haemorrhage he would be ordering a specialist post mortem.  5.6.34  The post mortem took place on 12th April, with DI1 in attendance. The initial post mortem indicated that Baby N’s death was suspicious. On the same day DI1 was made aware of the earlier injury to Child A during a conversation with SW3 from Croydon Children’s Social Care.  5.6.35  DI1 was of the opinion that the initial findings of the post mortem along with the information about the previous injury to Child A significantly increased the risk to the child. On 13th April the decision was taken to arrest Ms B and Mr C and to take Child A in to police protection. The police discussed the situation with Croydon Children’s Social Care Out of Hours Service and a SW was present at the removal of Child A. This was carried out in the early hours of the morning.  5.6.36 Had procedures been followed and a strategy meeting held following the admission of Baby N, the removal of Child A could have been carried out a planned way following a multi-agency assessment.   CSCB – SCR – Child A and Baby N Page 36 of 58      Learning Points  Children’s Services need to adhere to timescales and follow child protection procedures.  Police should have been informed that non-accidental injury was a possibility and a strategy meeting held.  Children’s Services need to ensure that they have understood medical information and not be led entirely by medical opinion.   Consideration should have been given to the safety of Child A.  Without a strategy meeting or a rapid response meeting the opportunity for a planned assessment of Child A was lost.  Agency checks must include the fathers of all children in the family 6 Analysis of Professional Practice 6.1 Children’s Social Care 6.1.1  Compliance with Policies And Procedures and Analysis of Practice. 6.1.1.2 Child A was referred by Croydon University Hospital to Croydon Children’s Social Care Out of Hours Service on 25th November 2014 having been presented to the emergency department with a large boggy swelling to the left side of her head. Child A was at this point only 5 months old and pre-mobile. The injury was said to be suspicious.  6.1.1.3 The following day 26th November Croydon University Hospital contacted CSC1 MASH with a further update. The information shared was that Child A had a possible skull fracture, there had been a delay of three days in seeking medical attention and the explanation given did not fit the injury.  6.1.1.4 Croydon Children’s Social Care did not follow procedures in dealing with the referral. The referral clearly met the threshold criteria for a S47 investigation as set out in the London Child Protection Procedures threshold document, i.e. an allegation of abuse or neglect or any suspicious injury to a pre or non-mobile CSCB – SCR – Child A and Baby N Page 37 of 58 child. This, together with the delay in seeking treatment and the inconsistent explanation for the injury should have moved the case from contact to referral and assessment, (S47) and triggered an immediate strategy meeting.  6.1.1.5 The procedures are also clear in that decisions to move to either a S47 or an assessment should be made within one working day. The case remained classified as a contact until closure on 11th December a total of 12 working days.  6.1.1.6 Staff within Croydon Children’s Social Care showed little understanding of indicators of abuse or neglect, over reliance was placed on the hospital reports that the child was physically well cared for. There appeared to be no professional curiosity7 or understanding of the role of social work assessments in assessing risk to a child.  6.1.1.7 Action was confined to undertaking basic background checks, which showed no prior concerns. Child A was 5 months old and an only child; the maternal family were from Portugal. Such checks in isolation, whilst essential, were of limited use. Again, professional curiosity might have led to further enquiries being undertaken,  6.1.1.8 On 9th December 2014 a notification was received from the Police, which documented a report by Child A’s mother that her father was threatening to take her out of the country, this directly contradicted the mother’s assertion that there was no contact with the father. This was not explored further.  6.1.1.9 Communication with other agencies was poor and not in line with procedures. The referral should have triggered an immediate strategy discussion with the police, this did not happen. No attempt was made to explore either the delay in seeking medical treatment or the explanation for the injury despite the fact that it was inconsistent.                                                        7 Professional curiosity is a combination of looking, listening, asking direct questions, checking out and reflecting on information received. It means not taking a single source of information and accepting it at face value. CSCB – SCR – Child A and Baby N Page 38 of 58 6.1.1.10 The SW response was led entirely by medical information and the case was closed without either the child or the family being seen and with no assessment of any kind having taken place. The cause of the head injury to child A remained unexplored and unresolved.   6.1.1.11 It is also worth noting that although the manager’s decision to close the contact was dated 11th December 2016, the letter to the Health Visitor was not actioned until the 12th December and not actually sent until the 16th December, some 5 days later. There was no prior discussion with the HV about the appropriateness of this request  6.1.1.12 On 15th March 2016, Baby N was admitted to hospital in a critical condition, the initial referral was passed to the Out of Hours service and picked up by Croydon Children’s Social Care MASH the following day 16th March 2016.  6.1.1.13 Following the transfer of Baby N to Evelina Children’s Hospital, a safeguarding referral was completed by the hospital and several telephone conversations took place between Croydon Children’s Social Care and medical staff which made it clear that non accidental injury had not been ruled out.  6.1.1.14 Croydon Children’s Social Care again failed to follow child protection procedures in that, despite the safeguarding referral and their knowledge of a previous head injury to Child A they did not progress the case beyond a contact. No strategy discussion took place, the police were not informed that there were potential safeguarding concerns and timescales were not adhered to.  6.1.1.15  It is clear from the recording that Croydon Children’s Social Care again used the lack of a definitive medical diagnosis as a reason not to take action and appeared to see their role as passive recipients of information. It appears from the recording that the SW involved had some concerns about the unresolved issues relating to the earlier head injury to Child A and felt that the case should be transferred she was however overruled by her managers. CSCB – SCR – Child A and Baby N Page 39 of 58     6.1.1.16 Again Croydon Children’s Social Care demonstrated no professional curiosity; on neither occasion was information sought about the father of the child even though there was extensive information held within the department relating to the father of Baby N, which was never accessed. Had procedures been followed and an early strategy discussion been held, information would have been shared about the previous injury to Child A, historical concerns about Child A’s father and Mr C’s history of domestic violence towards his previous partner.  This would have resulted in a much fuller understanding of the situation and enabled a planned assessment of the safety of Child A.  6.1.1.17 Following the death of Baby N, Croydon Children’s Social Care again failed to follow procedures. Despite clear information from Evelina Hospital that non-accidental injury remained a possibility and that the cause of death was unknown, they took the decision to close the contact. It is not clear how in the light of the information provided by the hospital, SW4 came to form the opinion that the death was not suspicious.  6.1.1.18 The information conveyed by SW4 to the police was inaccurate and misrepresented the medical information as to the cause of death. SW4 did not inform the police of the previous injury to Child A.  6.1.1.19  The inaccuracy and partial nature of the information conveyed to the police had potentially serious consequences :  A further opportunity for a strategy meeting was lost;  The information conveyed directly impacted on the decision not to hold a rapid response meeting;  The opportunity for a planned removal of Child A was lost;  Child A was left at potential risk.     CSCB – SCR – Child A and Baby N Page 40 of 58   6.1.2 Management oversight and decision-making 6.1.2.1 There was no supervision or management oversight on this case as it never at any point progressed beyond a contact.  6.1.2.2 Management oversight and decision making is demonstrated, however the quality of that decision making is of concern and does not demonstrate the expected knowledge of procedures and awareness of the indicators of abuse.  6.1.2.3 There is no evidence of appropriate direction or guidance being given to social workers by MASH Manager. The response to both referrals was to wait and be guided by medical opinion. The manager did not demonstrate an understanding of the risk factors present in the case, no information has been provided as to the rationale for the decisions that were taken. The lack of professional curiosity, poor inter agency communication and reluctance to undertake child protection assessments is of concern. CP procedures and timescales were not adhered to.  6.1.2.4 In relation to Child A the response was downgraded by the manager from amber to green despite the fact that the injury remained unexplained and no investigation or assessment had been carried out.  6.1.2.5 The management decision to ask the Health Visitor to conduct a follow up visit was a totally inadequate and inappropriate response in the circumstances. There was no direct discussion with the HV and the letter was not actioned until 16th December some 15 working days after the referral.   6.1.2.6 The CSC IMR notes that Mr C is known by both his maternal and paternal surnames and that these names have not been linked on the CSC recording system, this raises concerns about the quality of the information held by Croydon Children’s Social Care as the ability to cross reference names within the same family is key.   CSCB – SCR – Child A and Baby N Page 41 of 58    Learning points and Agency recommendations  Learning Points  Both incidents (Child A’s first admission; Baby N’s admission) involved a head injury to a pre-mobile child which should have led to the contacts progressing to a referral within 24 hours and a strategy meeting with a view to a s47 investigation.  CSC should ensure that all staff have a clear understanding of CP procedures and are knowledgeable about indicators of abuse.  There is a need to improve recording both to ensure accuracy and to document the decision making process   Professionals should be aware that, in some circumstances, agency checks will be of limited value and that professional curiosity might suggest the need for other enquiries to be undertaken.   Agency checks should be undertaken on the fathers and family members of any child coming to the attention of CSC  The response from CSC1 was passive and medically led.  CSC 1 need to be clear about their role in assessing risk to children and should not be passively led by medical opinion.  Croydon Children’s Social Care formed the erroneous opinion that the death of Baby N was not suspicious despite the view of Evelina Hospital that non-accidental injury remained a possibility and that the death was unexplained.  Communication with partner agencies needs to be improved, in particular Croydon Children’s Social Care need to ensure that they completely understand and accurately record medical information.  Communication with the police was poor. CSC need to ensure that they follow procedures at all times and that information sharing is accurate. Inaccurate and incomplete information was conveyed which had a direct impact on decision making.  Management decision making should be clearly recorded and in line with CP procedures  Children’s Services should ensure that checks are fully completed and that closed files can be linked to new referrals.  -    CSCB – SCR – Child A and Baby N Page 42 of 58    Agency Recommendations  Contacts: Case decisions should be made within the required timescales, taking account of all the available information when concluding if threshold is met.  Strategy Meetings: Medical information forms one element of the information about risk. Managers must take a holistic view based on all of the information available, including previous involvement with key players within the family, when deciding whether further intervention is required.  Re-Referrals: Professional curiosity should inform decision-making where there are repeat referrals, particularly related to pre-mobile/non-verbal children and physical injury; “think the unthinkable” should be a starting point.   Timescales: Repeat referrals will always generate renewed checks of all individuals within the household, including non-resident significant others.  Think Father: Fathers, including absent fathers and those reported to be uninvolved, and any current partner should always be a feature of assessment activity, to establish any past or current risk or to identify potential additional protective networks.     Understanding Neglect: Identification of neglect, its different presentations and impact, will be a key theme running through relevant multi-agency training delivered by the CSCB. The learning from this and other SCR’s which feature neglect as a key indicator of harm will be disseminated to the children’s workforce in Croydon.   Referral Outcomes: Referrers will receive an outcome notification via e-mail which is copied to the case record in all cases  Outcomes: Step-up/Step-down processes are only complete when a named worker has been identified and the case is formally transferred.  Records: All files/records related to key individuals within the child’s life should be linked.  CSCB – SCR – Child A and Baby N Page 43 of 58 6.2 St George’s University Hospital NHS Foundation Trust (St George’s Hospital.) 6.2.1 Compliance with Policies and Procedures and Analysis of Practice 6.2.1.1 Ms B attended St George’s Hospital for ante natal care with both of her pregnancies. Good practice was demonstrated by the booking MW on both occasions who asked Ms B if she had experienced domestic violence, she responded in the negative.  6.2.1.2 Details of the baby’s father were not recorded, this was not good practice. Ms B also disclosed a history of depression, which was not followed up at the time.  6.2.1.3 Ms B later disclosed that she was suffering from anxiety and panic attacks, this was appropriately followed up by MW2 with a referral to the Mental Health MW. MW4 also followed up Ms B’s non-attendance at a later appointment which was good practice.  6.2.1.4 On 27th July 2015, Ms B attended the Emergency Department at St George’s Hospital with Child A, who was suffering from red eye for which she had been treated by the GP. Whereas this attendance was not suspicious, there is no mechanism to cross check hospital records so the hospital would not have been aware of the previous attendances at Croydon University Hospital. Whilst this did not impact on this case, the lack of ability to cross reference at the point of attendance could potentially impact on other cases.  6.2.1.5 When Ms B attended for her second pregnancy details of the baby’s father were taken which was good practice. No safeguarding concerns were identified during either pregnancy  6.3 Croydon Health Service, Including Croydon University Hospital    and Croydon Community Service Integrated Trust (The IMR also  covers the Urgent Care Centre commissioned by Virgin Care  Services) 6.3.1 Compliance with Policies and Procedures and analysis of practice  CSCB – SCR – Child A and Baby N Page 44 of 58 6.3.1.1 When Child A was brought to the Emergency Department of Croydon University Hospital with a head injury, the hospital followed protocols and completed a timely medical assessment.  6.3.1.2 A referral was appropriately made to the Croydon Children’s Social Care MASH in line with the London Child Protection Procedures. The referral made it clear that the injury was inconsistent with the explanation.  6.3.1.3 Following further investigations the initial diagnosis of a skull fracture was changed and this was discounted, although it remained a serious injury (it has since been confirmed that Child A did in fact suffer a fracture to her skull.)  6.3.1.4 The injury remained however unexplained and at the point when Child A was medically fit the hospital contacted the MASH SW in relation to discharge. Neither organisation recorded this discussion adequately so it remains unclear how the decision was arrived at. Hospital records record that Croydon Children’s Social Care would be following up the family, which would indicate that the communication between the two agencies was unclear in that Croydon University Hospital may have been assuming that an assessment was to be carried out when in fact Croydon Children’s Social Care did not intend to progress the case beyond a contact.  6.3.1.5 Information was passed from the hospital to the Health Visiting Service in a timely manner in line with procedures, and the HV1 was already aware of the incident when she received the referral from Croydon Children’s Social Care. There was no discussion between HV1 and Croydon Children’s Social Care the HV had difficulty making contact with Ms B but there is no evidence that this was shared with Croydon Children’s Social Care, information sharing between agencies appears to have been minimal. The fact that the injury remained unexplained and there were difficulties in making contact following discharge did not prompt either a discussion between agencies or with safeguarding colleagues from health.  CSCB – SCR – Child A and Baby N Page 45 of 58 6.3.1.6 On 22nd May 2015 Child A presented at the Virgin Care Centre at Croydon University Hospital, with a further head injury. Although at the time this was felt not to be suspicious, it should have been seen in the context of the previous injury and prompted a referral to Croydon Children’s Social Care, particularly as the hospital records of the previous injury indicated that Croydon Children’s Social Care would be following up the family. Whilst it was unclear from the IMR whether previous records were accessed at the learning event, it was clarified that the patient card used in Care Centre would have included a summary of previous attendances at the hospital.   6.3.1.7 Record keeping was not in accordance with best practice and details of the man who accompanied Ms B and Child A to the hospital were not recorded, he was simply referred to as the father.  6.3.1.8 HV1 was made aware of the 2nd hospital presentation, had the two incidents been considered together and in more depth they might have prompted both a discussion with Croydon Children’s Social Care and a targeted one year review of the child. In the event, due to staffing difficulties the one year review did not take place.  6.3.1.9 Baby N was admitted to Croydon University Hospital on 15th March 2016, prior to being transferred to Evelina Children’s Hospital the following day. Discussions between Croydon University Hospital and Croydon Children’s Social Care during this brief admission are not addressed in any detail in either the chronology or the IMR. Croydon Children’s Social Care refer to a conversation with a ward sister following admission during which they were apparently told that there were no suspicious circumstances, Hospital records show that there was a conversation but the details were not recorded.   Learning Points and Agency Recommendations  Learning Points CSCB – SCR – Child A and Baby N Page 46 of 58  The initial diagnosis of a skull fracture was later discounted, we now know however that the initial diagnosis was correct and Child A had suffered a fracture to the skull.  Recording of communication between Croydon University Hospital and Children’s Services was unclear and there was confusion as to terminology.  Future actions need to be clearly recorded.  Croydon Children’s Social Care should have been informed of the second hospital presentation.     Agency Recommendations.  Record Keeping: Improvement in documentation when liaising with other agencies, this can be supported through safeguarding training and when delivering bespoke training to CHS staff. This is to promote the importance of record keeping in relation to rationale and decision making.  Standards: A Standard Operating Procedure will be implemented in relation to the process of children attending E D and the expectation of the timeframe in which Health professionals must follow up. The Named nurses and universal services have started a working group so the standard can be implemented within CHS.  Communication: Strengthen communication between CSC1 (MASH), CHS and the MASH Health Professional. This will be achieved through the MASH modernisation model and standard operating procedures implemented for the Health professionals within MASH so there are clear lines of roles and responsibilities.  6.4 Guys and St Thomas NHS Trust, Evelina Children’s Hospital Paediatric Intensive Care Unit 6.4.1 Compliance with Policies and Procedures, and analysis of practice. 6.4.1.1 Baby N was transferred to the specialist unit at Evelina Children’s Hospital on 16th March. Staff were alert to the possibility of non-accidental injury, from the start of Baby N’s admission to the intensive care unit there was a differential diagnosis of the possibility of non-accidental injury and the appropriate protocols were followed. CSCB – SCR – Child A and Baby N Page 47 of 58  6.4.1.2 The Trust Safeguarding Children Team were informed immediately of the admission of Baby N and were actively involved throughout. A full social history was taken along with the account of events from the parents. Recording was good and included information gathering from other agencies. Early contact was made with the MASH and an electronic referral completed it was made clear that both organic and non-accidental causes were being considered.    6.4.1.5 There were a number of telephone contacts between the hospital and the MASH SW who was kept informed throughout.  6.4.1.6 The safeguarding nurse SGN1 and safeguarding Dr, SG Dr1 were appropriately involved and consulted throughout the admission of Baby N. SG Dr1 was involved in the case review and management discussions with the treating clinicians, there was good joint working between the intensive care staff, specialist medical staff and the safeguarding team.   6.4.1.7 Croydon Children’s Social Care were notified of the death of Baby N in a timely manner, there was however a delay of around 9 hours in informing the Police. Staff experienced some difficulties in making contact and this was compounded by the fact that as no strategy meeting had taken place, there was no police reference number.  Learning Points and Agency Recommendations  Learning Points  Notifications of sudden or unexpected deaths to the police should be provided in a timely manner  Agency Recommendations  Guidance on unexplained / suspicious deaths: Revise guidance for notification to the police following an unexpected or possible suspicious child death  CSCB – SCR – Child A and Baby N Page 48 of 58  6.5 General Practitioners 6.5.1 Compliance With Policies and Procedures and Analysis of Practice.  6.5.1.1 IMRs were requested from GP practices responsible for the care of Mr C, Mr D and Ms B, Child A and Baby N.  6.5.1.2 Mr D is registered with a GP practice outside of London - the records contain no information of relevance to this review  6.5.1.3 Mr C is registered with a GP practice in Hammersmith and Fulham. Mr C had limited contact with his GP, there is nothing in the notes which would suggest that he posed any risk to a child. The GP had no information indicating that he had children or that he was living as part of another family outside of the area.  6.5.1.4 The author of the IMR highlights the importance of trying to ascertain which adults are involved in a child’s everyday life, and the dangers of having fragmented families registered at different practices, which increases the possibility that individual risks are not linked.  Learning Points and Agency Recommendations  Learning Points  There was no information in the GP’s records to indicate that Mr C had any children.  Recommendation for GP in Hammersmith  To use the recently developed templates on System One that can place all safeguarding relevant information in one place and the template that records in a child’s notes their immediate family so GPs can be aware of the whole family picture when seeing the patient. i.e. to highlight step families / step parents so a clear whole picture can be drawn when seeing a patient and a true calculation of risk made at each visit / presentation / clinical interaction.  6.5.1.5 Ms B, Child A and Baby N were registered with a GP in Croydon. Ms B attended the GP’s surgery regularly in relation CSCB – SCR – Child A and Baby N Page 49 of 58 to the health needs of herself and Child A. No concerns in relation to Ms B’s mental health or safeguarding capacity were identified. The only feature of note is that she presented with anxiety for which she was seeing a private psychologist having been turned down for cosmetic surgery. No information is available as to the identity of the psychologist or the content of these sessions.  6.5.1.6 Child A was brought to the surgery appropriately for routine medical care and immunisations. No safeguarding concerns were identified but the author of the IMR has identified areas where practice could have been improved. 6.5.1.7 Recordings of consultations did not routinely state who accompanied the child. Best practice in accordance with GMC guidelines is that consultations should be recorded in full, this would also have helped to build up a clear picture of who was caring for the child. Although no safeguarding concerns were noted it would have been best practice to record details of parent child interaction and to record the absence as well as the presence of safeguarding concerns.  6.5.1.8 GP1 received notification of Child A’s discharge from hospital following the unexplained head injury in 2014. As with the other agencies involved there was no evidence of professional curiosity despite the age of the child. It seems that the practice were reassured by the comment that Croydon Children’s Social Care were to follow up.  It would have been helpful to have had some follow up with Croydon Children’s Social Care to ascertain the outcome of their involvement.  6.5.1.9 It is of note that when interviewed the GP’s stated that they felt that inter agency communication needed to be improved. There is currently no formal mechanism for oversight of safeguarding issues within the practice; rather these are discussed on an ad hoc basis. The author recommends that a formal mechanism for review be established, in the form of a standing item at clinical meetings.  Learning Points and Agency Recommendations  CSCB – SCR – Child A and Baby N Page 50 of 58 Learning Points  Details of adults accompanying the child were not routinely recorded  There was room for improvement in recording relating to safeguarding   Inter-agency communication needs to be improved  There is no formal mechanism for oversight of safeguarding issues        Agency Recommendations for Croydon GPs  GP Surgery Management oversight of Safeguarding Concerns: The Croydon CCG safeguarding children team to promote by means of email communications/GP safeguarding leads workshop/ case reflection at individual surgeries the importance of management oversight of safeguarding cases, and suggest that this be a standing agenda item at GP surgery clinical meetings  Enhanced Inter-Agency Working: Social Care And Primary Care:  The Croydon CCG safeguarding children team to support the development of good communication pathways between GP surgeries and MASH when initial referral of a child made, including by means of the GP safeguarding leads workshops, at case reflection at individual GP surgeries and at GP/Social Worker workshops.  Enhanced Inter-Agency Working: Health Visiting Service And Primary Care: The Croydon CCG safeguarding children team to support the development of good communication between GP surgeries and health visitors by means of health visitor involvement at the July 2017 GP safeguarding leads workshop.   Good Medical Record Keeping: The Croydon CCG safeguarding team to promote best practice in medical record keeping in relation to children, with an emphasis on key safeguarding elements, by means of email communications, discussion at the GP safeguarding leads workshop and at case reflection at individual GP surgeries.  CSCB – SCR – Child A and Baby N Page 51 of 58 6.6 Metropolitan Police Service, Specialist Crime Review Group.  6.6.1 Compliance with Policies and Procedures and Analysis of Practice 6.6.1.1 There was no involvement from the Serious and Complex Case Team until after the specialist post mortem which was undertaken following the death of Baby N. Inter-agency communication was poor and the Police were not informed of the unexplained head injury suffered by Child A in 2014,or the opinion of Evelina Children’s Hospital that non-accidental injury remained a possibility and that the death of baby N was unexplained   6.6.1.2 MASH requests for exchanges of information are not included on the MPS database so there was no record available to the police that there had been previous concerns about an injury to Child A. The IMR has also highlighted the lack of any information sharing agreement or operating protocols between the MPS and Croydon MASH.  6.6.1.3 A rapid response meeting was not held because Baby N’s death was not “unexpected”, i.e. it could have been predicted within the previous 24 hours.  It is unfortunate that the criterion excludes children whose death would not have been expected a few days beforehand; if the rapid response procedures had been initiated it would have provided an opportunity for information sharing between agencies and for a joint risk assessment to have been undertaken in relation to the safety of Child A.  6.6.1.4 A notable feature of this case is the poor inter agency communication, the lack of information sharing and the absence of any multi agency meeting to look at the situation in the round.   6.6.1.5 The police became aware of the previous head injury to Child A at a late stage, following the receipt of the findings of the post mortem in relation to the death of Baby N. This led to a discussion with CSC Out of Hours Service and a decision to remove Child A during the early hours of the morning and arrest Ms B and Mr C. Had there been effective inter agency communication from the outset in the form of a strategy CSCB – SCR – Child A and Baby N Page 52 of 58 meeting, or a rapid response meeting, measures to ensure the safety of Child A could have been taken in more planned way.  Learning Points and Agency Recommendations  Learning Points  MASH requests for information should be included on the MPS database   An information sharing agreement and operating protocol should be developed between Croydon Children’s Social Care MASH and the Police Agency Recommendations  Recording: That the MPS implements a system to ensure that MASH requests for exchange of information are recorded on an MPS database.  Information Sharing Protocol: That the Croydon BOCU Senior Leadership Team in conjunction with the Local Authority and partner agencies establish an Information Sharing Agreement and operating protocols for staff working within the MASH.   7 Conclusions 7.1 Comment 7.1.1 There have been difficulties throughout the review process in securing the compliance of all agencies, both in terms of meeting timescales for submission, following guidelines as regards anonymisation and understanding how to complete a chronology that is fit for purpose.  7.1.2 The quality of the IMRs submitted has been variable. Although some agencies have responded to requests for additional information in a timely manner, there have been particular difficulties in securing responses from Croydon Children’s Social Care. It has not been possible therefore to understand or analyse why particular decisions were made. In particular it has not been possible to fully understand why the initial referrals in relation to both Child A and Baby N were not considered to be child protection and why child protection procedures were not adhered to. Similarly during the course of the review, it was not possible to explore further whether the practice of keeping cases open as CSCB – SCR – Child A and Baby N Page 53 of 58 contacts rather than progressing them to assessments was a systemic problem and the extent to which it had been addressed. However, since the period under review, progress has been made and recognised by Ofsted in recent inspections.   7.2 Multi Agency 7.2.1 Croydon Safeguarding Children’s Board may wish to reflect on the contributions of partner agencies to this review. The author is aware that CSCB was undertaking a number of reviews at the same time and that resources were stretched.   7.2.2 The SCR process has highlighted a number of issues in relation to inter agency communication. Throughout this case there were a number of occasions where communication between agencies was poor.   The Police were not informed of the hospital admission of Child A in 2014 with a serious head injury.  There was no direct communication between Croydon Children’s Social Care and the HV service in relation to the follow up of Child A’s hospital admission in 2014.  Croydon Children’s Social Care were not informed of the second hospital presentation of Child A, again with a head injury.  Although the Police were aware of the hospital admission of Baby N, they were not informed of the opinion of Evelina Hospital that non-accidental injury was a possibility.  There was delay in informing the Police of the death of Baby N. Evelina Children’s Hospital experienced difficulty in making contact. This was compounded by the fact that there was no Police CAD number. Had a strategy meeting taken place in line with procedures this issue would not have arisen.  As a consequence of the failure to share information contemporaneously about the original head injury to Child A or about the possibility that the death of Baby N was attributable to a non-accidental injury, Child A was removed from home outside of office hours in what must have inevitably been traumatic circumstances.  7.2.3 There was a lack of understanding of the role and function of the MASH.  Croydon University Hospital considered that they were CSCB – SCR – Child A and Baby N Page 54 of 58 making a referral of Child A in relation to safeguarding concerns, Croydon Children’s Social Care only opened a contact and never progressed the case to a referral or assessment8. Croydon University Hospital were also under the impression that CSC1 were going to follow up Child A post discharge, where in fact Croydon Children’s Social Care simply closed the contact.  7.2.4 There were discrepancies between agencies understanding of what was being said by the medical staff involved during the hospital admission and death of Baby N. Incomplete information was passed from one agency to the other in particular from Croydon Children’s Social Care to the Police leading to decisions being made without the full facts of the case, for example the decision not to hold a rapid response meeting.    7.2.5 There were a number of occasions where details of the father(s) were not taken or researched. Croydon Children’s Social Care had known Mr C’s family for many years, they held extensive information about his background and childhood which was not accessed at any point prior to the death of Baby N. Consequently, the father(s) were invisible to professionals.  7.2.6 When Child A attended hospital on the second occasion, details of the male who attended with her and Ms B were not taken.  7.2.7 The hospital records of the birth of Baby N do not state whether his father was present despite him being mentioned in Ms B’s birth plan.  7.3 Record Keeping 7.3.1 There were a number of instances of poor record keeping. From the information presented by Croydon Children’s Social Care it is not possible to follow how decisions were made, some information appears not to have been recorded and there appear to have been a number of inaccuracies which were recorded and                                                       8 When Croydon Children’s Social Care MASH receives information (a contact), they evaluate that information before deciding whether to act upon it (a referral) which would usually be by progressing the referral to an assessment.  CSCB – SCR – Child A and Baby N Page 55 of 58 then repeated and passed on to other agencies. For example the injury to Child A was repeatedly said not to be suspicious when in fact there remained a number of unanswered questions which had not been explored. Similarly the injuries to Baby N were said to be not suspicious when in fact non-accidental injury had not been ruled out and his death was unexplained.  7.3.2 Record keeping and recording in health services did not always reflect fully discussions or decision making, names of professionals were not always recorded, for example the discussions between Croydon University Hospital and Croydon Children’s Social Care following the admission of Child A were not clearly recorded by the hospital.  7.3.3 Recording by the Police was not always clear in that names of SW were not always recorded and the discussion in relation to the decision to remove Child A into police protection is not recorded.  7.4 Compliance with Child Protection Procedures 7.4.1 There was a repeated failure to follow child protection procedures. There were at least three occasions on which a strategy discussion should have been considered.  First presentation of Child A with a serious head injury. This was a pre-mobile child with a serious head injury requiring hospital admission where there had been a delay in seeking medical attention. In addition the explanation given did not match the injury.  Second presentation of Child A with a head injury, when considered alongside the previous unexplained head injury.  Admission/ Death of Baby N where the cause of his death was unexplained and a subdural haematoma had been diagnosed.  7.4.2 Croydon Children’s Social Care MASH did not adhere to timescales, decision-making was poor and not in accordance with the London Child Protection Procedures.  The initial referral of Child A should have triggered a strategy discussion and a S47 investigation, as should the referral of Baby N. The lack of a strategy discussion on both occasions seriously hampered interagency working and led to the Police being unaware of the injury to Child A until after the death of Baby N. On both occasions CSCB – SCR – Child A and Baby N Page 56 of 58 Child A was left at potential risk with no attempt being made to assess her safety. The failure of Croydon Children’s Social Care to progress clear safeguarding concerns and the lack of compliance with the London Child Protection Procedures is a serious omission.  7.5 Professional Curiosity 7.5.1 There was a lack of professional curiosity displayed by some professionals. Croydon Children’s Social Care did not complete any assessment of the family until after the removal of Child A following the death of Baby N.   7.5.2 The Urgent Care Centre at Croydon University Hospital did not contact Croydon Children’s Social Care in relation to the second head injury to child A, despite having access to her records indicating that this was the second such injury.   7.5.3 Croydon Children’s Social Care did not hold a strategy meeting following the admission of Baby N despite being made aware that non-accidental injury was a possibility and despite knowing that Child A had suffered a serious and unexplained head injury which had been the subject of an earlier referral/ contact.  7.5.4 Croydon University Hospital initially reported to the police and Croydon Children’s Social Care that the condition of Baby N was not suspicious.  7.6 Research in relation to Head Injuries in Infants 7.6.1 It is important that all practitioners keep abreast of research in relation to all aspects of child protection. It is the responsibility of LSCBs as well as individual agencies to ensure that research and learning is disseminated to all staff whether though training or otherwise.  7.6.2 A longitudinal study of accidents involving children under the age of six months found that significant injury in a domestic setting is rare. Whilst falls of various types were the most common accidents, injury only occurred in 15% of falls. Most injuries were CSCB – SCR – Child A and Baby N Page 57 of 58 minor; 97% involved the head. Fractures occurred in less than 1% and most were simple skull fractures.9  7.6.3 According to the Royal College of Paediatrics, studies of head injuries in infants have shown that head injuries are the commonest cause of death in physical child abuse. 97% of severe head injury in the first year of life is inflicted and non-accidental head injury is most commonly seen in infants under the age of 6 months. Accordingly, paediatricians are advised that a diagnosis of non-accidental head injury should be considered for any infant who inexplicitly collapses and paediatricians must maintain a low threshold for considering diagnosis.10   7.7 Conclusions 7.7.1 It is not possible to say whether the injuries to Child A and the death of Baby N could have been predicted or prevented. In relation to the first injury to Child A it is clear that it could not. She was not previously known other than to universal health services, and her mother had no history of previous involvement. However, this injury should have triggered a strategy meeting and a child protection assessment that might have identified risks within the household. Had there been such an assessment the second injury would have triggered a more in depth consideration. An assessment would also have given the opportunity to explore the backgrounds and involvement of the fathers of both children.  7.7.2 In the absence of any assessment it is also difficult to comment on the death of Baby N, whereas an assessment might have uncovered risk factors and a consideration of the background of the baby’s father might have highlighted potential difficulties. However, this would still not have made Baby N's death either predictable or preventable.                                                        9 The Avon Longitudinal Study of Parents and Children (ALSPAC) 10 Royal College of Paediatrics CSCB – SCR – Child A and Baby N Page 58 of 58 7.8 Additional Recommendations 7.8.1 The CSCB to ensure the full participation of all agencies in (serious) case reviews, both in relation to attendance at meetings and responding to requests for information.  7.8.2 The CSCB to ensure that authors of IMRs are given training on completion of chronologies, interviewing staff and writing IMRs  7.8.3 The findings of research into head injuries in children to be included in interagency training.  7.8.4 The CSCB should undertake an audit of information sharing between agencies including between agencies in the MASH.  7.8.5 Through case audits the CSCB needs to be satisfied that issues relating to compliance with child protection procedures, invisible fathers, professional curiosity and recording are being addressed on a multi-agency basis.  7.8.6 CSCB should seek assurances from partner agencies that all supervisors and managers are equipped with the skills and knowledge to provide effective supervision and management oversight of child protection cases.  7.8.7 CSCB should ensure that the revised MASH protocols and information sharing agreements are fit for purpose.  7.8.8 In the light of the current review of Working Together and, in particular, the review of the arrangements for reviewing child deaths, no recommendation is made in respect of rapid response meetings / child death overview panels. However, it is of note that a rigid definition of an unexpected death that restricts the definition of unexpected to 24 hours is unhelpful and potentially misses an opportunity to review some children who may have died as a result of abuse.      