Executive summary of a review into the death of a baby as a result of a traumatic head injury, which the postmortem concluded could not have occurred without some force. The immigration status of mother was that she had limited leave to remain in the UK following her marriage to father. Father had some learning difficulties, which was not known to mother before the marriage. Prior to Child 1s birth mother, father and Child 2 lived with father's extended family. After moving to their own accommodation mother and father reported that paternal grandfather was physically abusive and controlling and managed their finances, including father's disability allowance. Mother had previously disclosed domestic abuse and unhappiness with father to her GP. Identifies lessons learned, including: significance of mother's vulnerabilities in relation to her arranged marriage, father's learning difficulties, her social isolation and her immigration status; and recognition of the importance of domestic abuse disclosures however low-key they may appear. Makes recommendations covering children's services, GPs, housing, hospital and ambulance services.
      
 Title:  Serious case review executive summary in respect of Child 1. LSCB: Bolton Safeguarding Children Board Author: Hester Ormiston Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          SERIOUS CASE REVIEW EXECUTIVE SUMMARY  In Respect Of  Child 1    Executive summary prepared by:-  Hester Ormiston, Independent Author  Signature:-     Executive summary endorsed by:-  Mike Tarver, Independent Chair of BSCB  Signature:  1  1  1. Introduction Page 3  2. Process of the review Page 3  3. Summary of events that lead to the child’s death Page 6  4. Race, Language, Culture, Religion and Disability Page 6  5. Background of the family Page 6  6. Overview of the serious case review Page 7  7. Summary Page 8  8. Learning from the review Page 9  9. Recommendations 9.1 Summary of SCR Recommendations Page 10 9.2 Summary of IMR Recommendations Page 10 9.3 Summary of PCT Commissioning Health Overview Report  Page 12  10. Appendix:   Terms of Reference Page 14   2  1. INTRODUCTION  1.1 This report is a summary of the findings of a Serious Case Review (SCR) of how agencies worked together to provide services for the child who died and his family.  The SCR was conducted in accordance with government guidance Working Together To Safeguard Children 2010, which expects Local Safeguarding Children’s Boards (LSCB) give consideration to conducting a SCR:  When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family.  This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family.   1.2 The chair of Bolton Safeguarding Children Board, Mike Tarver, agreed soon after the death of the child concerned that a SCR should be convened because  the circumstances indicated that abuse or neglect were suspected to be a factor in the child’s death.  Ofsted had already been notified of the details of the child’s death from an unexplained cardiac arrest and that a Serious Care Review (SCR) may be held.   1.3 The purpose of the SCR was to:  • Establish what lessons are to be learnt from the case about the way in which local professionals and agencies work individually and together to safeguard and promote the welfare of children;  • Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result and;  • Improve intra and inter-agency working and better safeguard and promote the welfare of children.   2. PROCESS OF THE REVIEW  2.1  The panel overseeing the SCR was chaired by an independent person, Vlasta Novak, who is an independent social care consultant. Vlasta has experience of management and inspection in the field of safeguarding.  She has chaired several SCR panels.   2.2 As part of the process, the panel discussed individual management reports (IMRs) prepared by each agency that had provided services to the family while they lived in Bolton.  The panel ensured that each author of the IMRs had thoroughly examined the role of their agency and identified where lessons could be learned and things done differently in future. 3  2.3 The panel comprised: • Vlasta Novak, the Independent Chair • Assistant Director, Bolton Children’s Services  • Detective Inspector, Serious Case Review Team, Greater Manchester Police  • Member from the Bolton Council of Mosques • District Manager, Bolton Children’s Services  • Associate Director Safeguarding (Designated Nurse), Bolton PCT  • Consultant Paediatrician, Designated Doctor for Safeguarding, Bolton PCT  • Head of Personalisation & Inclusion, Adult Community Services  • Housing Options and Advice Services Group Manager, Bolton Council Community Housing Services  2.4 The panel met five times.  The overview report was written by an independent author, Hester Ormiston, who attended each meeting of the panel.  Hester Ormiston is a social care consultant who has management and inspection experience in relation to safeguarding services, and has written a number of overview reports.  Working Together 2010 requires the author of the overview report to be a person who is independent of all the local agencies and professionals involved and of the LSCB.  2.5  At the first meeting, the panel agreed terms of reference (Appendix 1) which identified the main questions to be answered in each IMR and the Overview Report.  Working Together 2010 asks that reports should not include details of children and family members to protect their identity.  2.6 The review covered the time the family first lived in Bolton until the day the suggested cause of his death was known.  2.7 The following agencies were asked to provide IMRs: • Bolton NHS Foundation Trust (to include midwifery, health visiting and Hospital 1) • General Practitioner services • Bolton Council Community Housing Services • Bolton at Home • Children’s Services Staying Safe and Children’s Centres (combined report)  • North West Ambulance Service • North West Transport Service, and • A NHS Commissioning Health report drawing together findings from the five NHS reports 4  2.8 Each IMR was written by a person who had not had any direct involvement with the family as a practitioner or practitioner’s supervisor to ensure the agency critically examined how services were provided.  BSCB procedures expect a good standard of report writing, but offer comments from the panel to ensure this standard can be met.  All the reports have been completed to a high standard in written styles which are clear and informative.  2.9 The following agencies also had some information on the child’s family but the panel confirmed that it was brief and insufficient to merit an Individual Management Review (IMR).  These agencies were asked to provide statements of involvement. • Greater Manchester Police • Adult Services Bolton • UK Border Agency • Children’s Legal Services Bolton; a summary of care proceedings  2.10 Area 4 LSCB (where the child’s father had lived as a child, and his mother lived when she married into the family) was asked to provide information from each agency that had a record of the child’s father and his extended family, who lived at the same address.  This included any information from records that may indicate the strengths and vulnerability of the child’s parents.  The child’s older sibling was born while the family lived in Area 4.  The information provided was very helpful in understanding more about the life of the family before their move to Bolton.  Hospital 3 NHS Foundation Trust which had brief contact with the child was also asked to prepare a report.  2.11 Following consultation with the police, the chair of the panel wrote through their solicitor to the child’s parents, and later to the aunt and uncle. The chair, with Bolton Safeguarding Board Officer, met the aunt to talk about the services offered to the family. She was positive about the services offered, especially the Children’s Centres, but considered more could have been offered in terms of general advice on caring for a baby and information on support available within the community. She made the point that the child’s family unusually was not living with the support of the extended family.  2.12 Following endorsement by Bolton Safeguarding Children Board and in preparation for publication further engagement was undertaken with the family.  Adult 1, Adult 2 and Adult 5 all had the opportunity to read the report in full before publication.  In response to their feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that all dates, as well as gender references relating to the children would be removed from the report.  It was agreed this did not detract from the learning.  5  2.13 Adult 1 also wished to state she disputes the record that she was not happy with the second pregnancy.  She has reported that this was a planned pregnancy, she was happy about this but she was unhappy with the circumstances between her and Adult 2. In response to this feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that this would be noted in the report but this is what she is believed to have said at the time.   3. SUMMARY OF EVENTS LEADING TO THE CHILD’S DEATH   3.1 The child was taken to the GP’s surgery in the afternoon.  After the child had been examined the family were given advice and they returned home.  Shortly after the return home, the child was found to be unresponsive.  The mother ran into the road with the child and a neighbour rang for an ambulance.  The same neighbour took the child into his own house and began cardio pulmonary resuscitation.  The child was taken by ambulance to hospital and places on a life support machine but later died.  3.2 The provisional post-mortem findings suggested that the child had suffered a fatal traumatic head injury.  Neither parent had an explanation for the injuries at the time.    4. RACE, LANGUAGE, CULTURE, RELIGION AND DISABILITY  4.1 The immigration status of the child’s mother was that she had limited leave to remain in the UK when she arrived from Area 3 following her marriage.  The family are Muslim with the child’s mother speaking Urdu and Hindi.  The child’s father was born in Area 4 where his parents, who are UK citizens, still live.  He has been in receipt of some disability benefits because he has a learning difficulty.  Throughout the timescale of the review, with the exception of the Children’s Centre (where other parents attending spoke Urdu) both parents were observed to speak good English and did not need an interpreter.   5. BACKGROUND  5.1 The child’s father had lived in Area 4 from birth and it is known that he had some learning difficulties meaning that he was unable to read, write and communicate in line with his chronological age.  The child’s parents were married in Area 3, with his mother joining his father at the family home in Area 4.  After the child’s elder sibling was born the family found living with the extended family more difficult.  They preferred to live separately and so moved to Bolton; living initially with other family members who had also moved there.  5.2 With support from their relatives, they applied for and then moved into their own tenancy.  The child who died was born eight months later.  6  6.  OVERVIEW OF SERVICES  6.1 The family received services during their time in Bolton from NHS community staff, health visitors and midwives, GP practice staff, Hospital 1 and the Tenancy Sustainment Service (a service offered to young adults to help them to maintain the tenancy) from Bolton at Home, their landlord.    6.2  Additionally the child’s sibling received services from some specialist NHS services because of some delayed development.  The family kept appointments, worked well with staff from the different agencies and provided a good standard of care for their elder child.  6.3 Bolton Children’s Services provide a universal Children’s Centre service to support families with young children to take part in activities with their children and to get support from mixing with other parents.  The child’s mother attended two Children’s Centres.  There were no concerns about the care given to her eldest child.  Additionally the child’s mother attended a different Children’s Centre five times for her antenatal care during her pregnancy.    6.4  As the child’s mother became familiar with the NHS staff, she talked about some difficulties in the family, both practical and emotional.  At times she indicated that she was lonely and would like to have support from her family in Area 3.  Previously on one visit to the GP that the family was first registered with, the child’s mother had talked about her loneliness and some unhappiness both locally and when living with her husband’s family.   6.5  It would have been helpful if the earlier information had been known to the Community NHS staff.  After the child’s birth, the midwife made a referral for family support but the referral could have been more complete, showing the family were receiving services from more than one agency.   6.6  The Children’s Centres oversee the process of providing family support, either informally, or within a formal plan.  The local centre received the midwife’s referral for family support when the child was about 2 weeks old.  The referral did not indicate a high level of priority and so the service was planned to start a few weeks later, rather than more immediate support.  The service, following the review, acknowledges that a Common Assessment Framework (CAF) should have been made so that all agencies could consider any additional support needs of the family.  6.7  When the child was taken to hospital by ambulance the services provided to the family were expert, prompt and sensitive.  They took full account of the cultural and language needs of the family and treated them with respect at all times, even when explaining the need to follow procedures for an unexplained serious injury and eventually death.    7  6.8  A recommendation in the NHS commissioning report is how to manage an Acute Life Threatening Event (ALTE) for a baby or young child.  All LSCBs have arrangements of what to do when a child dies from an unexplained injury or medical condition, but Hospital 3 has included within the procedure how to manage ALTE as well.  The procedure includes timetabling notification to the appropriate police force, should it be necessary to secure a possible crime scene.  In this case, notification to the police was delayed because of lack of clarity on whose role it was.  This procedure is not used in all LSCB areas and not in Bolton.    7. SUMMARY  7.1 The narrative on each IMR and the responses to the Terms of Reference indicate that agencies worked competently, mainly meeting expected standards of practice and with an understanding and respect for the cultural identity of the family.  Records describe a young couple who showed maturity, ability to manage the household, with a warm and caring approach to parenting.  7.2 Most contact with the family was from staff from universal NHS services provided, but with increased support and specialist NHS services when assessments demonstrated the need.   7.3 When the child’s mother used services at the Children’s Centres she was able to meet with other parents who spoke Urdu.  Her attendance was not consistent, but this is an expected pattern with families encouraged to use the service when they want to.  7.4 Housing services provided a prompt assessment of need, recognised when the family’s needs became more urgent and as part of the Successful Tenancy Plan (STeP) programme provided more support to maintain the tenancy because of their young age.  7.5 When the child was in cardiac arrest, emergency services and both hospitals provided prompt, specialist, and sensitive care.  7.6 The individual reports identify some occasions of poor or missed communication, but on the whole communication within and between services was good, and recorded in detail.  7.7 The key area where, with hindsight, agencies acknowledge a better service could have been provided is an understanding of the context of the couple’s capacity to parent.  Assessments did not complete the picture of the child’s mother needing more personal support and her possible acceptance of domestic abuse and the child’s father possibly needing more direct input to help him to parent because of his learning difficulty.  Equally, except for housing agencies, it was not known for some time that the family had moved from a controlling atmosphere within the extended family.  8  7.8 The panel discussed the level of need for family support demonstrated when, with hindsight; information from all agencies was combined into one list giving a fuller picture of possible vulnerabilities.  There were some missed opportunities to give the child’s mother information and guidance on how to get more support from within the community.  However panel agreed that even with the fuller picture, the family needs did not meet the threshold for intervention, or for a formal co-ordination of services using a Child Action Meeting (CAM).  7.9 It is within this context that the panel concluded that the death of the child was neither predictable nor preventable and there was no indication of any risk of harm.   7.10 The panel noted the difficulties for staff who have a responsibility to assess risk, but maintain a balance between support and respect for privacy in family life in the provision of universal health and family support services.   8. LESSONS LEARNED FROM THIS SCR  8.1 The review has confirmed that the agencies provided good, prompt, sensitive services, taking account of the needs of the family.  All observations of parenting were recorded and were consistent in noting a good standard of care.  There was no concern by any agency and the review, with hindsight, has not identified any risk that could have been acted on at any time.  8.2  Each agency has identified individual recommendations, mainly linked with improving records or direct communication.  The panel considered that apart from these the recommendations led to three main areas of learning from the SCR.  They are:  1. Recognition of the importance of domestic abuse, however low key the disclosure appears to be, when there are children in the household.  It is possible that the child’s mother would have talked to NHS staff in Bolton about family life in Area 4 much sooner, giving a clearer picture of their lives.   2. Recognition of how a number of small matters can make a family vulnerable.  There was only partial recognition of how a number of circumstances could lead to the child’s mother feeling isolated.  Some of these were practical, like damp in the house, and some emotional, like her immigration status and her wish for support from her own family in Area 3.   The agencies did not fully understand any possible impact the child’s father’s learning difficulties might have had on his parenting or management of family matters, and so staff did not ask more about it.    If staff had explored more about the roles taken by each adult in the family, the vulnerability of both parents may have been known earlier.    9   With all the information now gathered about the two adults, it is accepted that it would have been appropriate for the family to be offered more advice and information on community groups which could have provided the child’s mother with support from other parents.  3. Use of Acute Life Threatening Event (ALTE) protocols.  The review has found that through a series of missed opportunities, the police were not informed of the unexplained death of the child until two days after his admission to hospital.  Hospital 3 has a pro-forma (ALTE) for use when a child has an unexplained life threatening illness or injury which expects the local children’s services and the police are notified.    The ALTE pro-forma is in place to ensure that all agencies are alert to the possibility of beginning procedures linked with safeguarding.  These three areas of learning are reflected in the recommendations in the NHS Commissioning report and the GP IMR.  The SCR panel has no further recommendations.   9. RECOMMENDATIONS  9.1 Summary of SCR Recommendations  This review has found a good standard of practice in all agencies.  The family were provided with a range of universal services that met their needs, taking account of their culture and language.  Within the NHS in particular the agencies can be proud of the quality of service provided as a routine and at the time of the emergency.  However, as always when services are examined in detail, there is learning leading to some recommendations to improve practice or develop services further.  9.2 Summary of IMR Recommendations  Hospital 3 recommended that:- • Record keeping issues highlighted within the addendum report shall be used as a basis for learning with both the health professionals directly involved in the care of the child and as part of the mandatory safeguarding training provided to all health professionals across the organisation. • Health Overview Author makes a recommendation to the Northern Strategic Health Authority to request all LSCB’s across the region review and amend their current SUDI/SUDC protocol to include guidance on the management of a child suffering an ALTE, which would include triggering a referral to Children’s Services and the Police.   10  Bolton at Home recommended that:-  • Introduces electronic storage of STeP assessments  • Reviews its contact processes for customers  • Reviews the collation and recording of customer information as part of home visit process  Bolton NHS Foundation Trust recommended that:-  • All services have up to date knowledge and skills about domestic abuse   • Awareness is raised with relevant staff about the CAF process specifically when to initiate CAF and develop CAF skills  • Children’s identity issues are explored when health services are provided  • Assessment and recording in relation to attachment is further developed  • Review oversight of the work of support staff in Health Visiting teams- specific to HV Teams  • Consider implications of research and practice developments in other areas for keeping infants safe  • Remind relevant Foundation Trust staff of the Sudden Unexpected Death of Children process in relation to ensuring that contact has been made with the police  • Increase awareness of the vulnerability of infants to include all services in community and acute setting  Children’s Services recommended that:-  • To ensure the registration forms in the Children Centres are fully completed at the time of registration. To check details are up to date on the registration form if families present at a different centre.  • Review the signing in process, to ensure all names are captured and match with the registration forms.  • Consider a general overview recording of each session and to think about how learning can be transferred into the home.  • Review the referral process to the MARP.  11  Community Housing Services recommended that:-  • Case record/Visit forms should be amended to indicate all individuals present during contacts  • Briefing note to staff regarding change to record keeping  GP recommended that:-  • Promote as good practice referring cases of domestic abuse to Health Visitors where preschool children are in the family and code the domestic abuse in the records.  • Promote as good practice stripping off babies fully for examination by GPs  North West & North Wales Paediatric Transport Service (NWTS) recommended that:-  • Ambulance staff to undertake safeguarding training  North West Ambulance Service (NWAS) recommended that:-  • NWAS Safeguarding Children Policies and Procedures are strengthened in relation to taking into account issues of ethnicity, diversity, culture and language which may pose barriers. Current policy and procedures due to be updated.  • Specific reference to ‘language- line’ will be added into the policy and procedures to ensure staff can communicate effectively with patients and relevant others.  • Update the Sudden Untoward Death of Children Procedures to ensure that during any Acute Life Threatening Event (ALTE) or sudden untoward death of a child, the police must be notified by the relevant Emergency Control Centre Call Taker.  9.3 Summary of PCT Commissioning Health Overview Report     The PCT Commissioning Health Overview Report recommended that:-  • Greater Manchester LSCBs and NHS Greater Manchester to amend the current Protocol “Sudden Unexpected Deaths in Childhood” to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE).  This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis.  12  • Bolton Foundation Trust to consider adopting the ALTE pro-forma for use in children who remain in Bolton for their investigation and treatment.  This should specify explicitly who will be contacting each agency involved and when this has been done so that there is no delay in involvement of any individual agency.  • Hospital 3 to review the ALTE pro-forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed.  • Raise awareness of the impact of additional stressors including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties.  This recommendation relates to frontline health workers responsible for assessing children and families’ needs and also managers responsible for clinical supervision.  13  APPENDIX  Terms of reference:  1.  To what extent did agencies/services/individuals recognise and take account of mother’s potential vulnerabilities, in particular:- • Age • Language and literacy needs • Immigration status • Marital status • Level of isolation or integration within the local community • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes  2. To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:- • Age • Learning disability/difficulty • Marital status • Parenting capacity • Level of isolation or integration within the local community • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes  3. What opportunities did the agency have to observe parenting capacity and interaction between the mother and the father with the child and the sibling?  What impact did this have on assessments, actions and services offered at the time?  Is there anything that could have been done differently?  4. To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues?  5. What opportunities did the agency/service provide to the mother and the father to speak independently of one and other about any concerns or worries they had prior to the birth of the child?  On reflection can you identify any learning points?   14  6. To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family?  What was the response of the agency and how did this feature in assessments, planning and interventions?  7. On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work?  8. On reflection were there any signs or indicators that the child was at risk of suffering significant harm or other missed opportunities to safeguard this child?  Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this.   15  