Severe burns and injuries to a 1-year-6-month-old boy in December 2019. Medical opinion was that the injuries were non-accidental, and were likely to have been inflicted or were due to a significant lack of supervision and neglect. Learning includes: experiencing significant trauma, adversity or loss as a child may contribute to parenting capacity being compromised; where there are multiple risk factors, the importance of thoroughly assessing each one to understand which needs might be associated with which risks; practitioners should link and analyse facts about parental issues which may have an impact on a child's safety, with records reflecting thinking processes; the importance of consistency and continuity of social workers, to build trust and to monitor any developments that may negatively impact a child; the importance of revising initial assessments about a child's circumstances, as failing to review these may result in risk to the child; chronologies can be key for understanding needs and risks, and can support assessment and risk management. Makes recommendations to the safeguarding partnership, including: consider an audit of open cases where anonymous referrals are made, to ascertain the quality and effectiveness of the assessment and response; consider a multi-agency audit on how thresholds are applied by children's services in cases where there are concerns about unborn children; raise the profile about the need for practitioners to be professionally curious about male associations with vulnerable women.
      
 Title:  Child safeguarding practice review: Aiden. LSCB: Berkshire West Safeguarding Children Partnership Author: Kevin Ball Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           FINAL VERSION 0 Child Safeguarding Practice Review Aiden Independent Reviewer: Kevin Ball  FINAL VERSION 1 Synopsis of the review 1.1. This Child Safeguarding Practice Review (CSPR) examines the involvement of professionals and agencies with a young child, who for the purposes of this report will be known as Aiden. In December 2019 Aiden, aged 1½ years, was admitted to hospital with severe burns to his stomach and hand. At the point of admission Aiden had limited verbal language but was very distressed and in trauma. Medical opinion was that the burns were non-accidental and likely to have been inflicted or pointed to a significant lack of adult supervision and neglect whilst in the family home. A Police investigation has concluded that no further action will be taken.1.2. The purpose of the independent review is to capture any learning as a result of the incident, as well as attempt to establish and explain why events occurred as they did. 1.3. The review, which has adhered to statutory guidance1, provides an analysis of professional practice from a multi-agency perspective and has offered recommendations as a means of improving and strengthening practice so as to prevent or reduce the risk of recurrence. 1.4. By way of a summary, the following findings have emerged; -There were a number of pre-disposing risk factors in the mother’s history that justified a thorough and robustassessment of her capacity to care for a young child prior to birth. Despite repeated requests by the MidwiferyService and Health Visiting Service, the assessment completed by Children’s Services was very limited.-Initially, both parents appeared to be caring well for Aiden however the extent of the care and support themother had been receiving in her own right, prior to the birth was not fully recognised. The transition fromhigh support to greater independence and the impact of also having to parent a baby was also not assessed.-The mother’s high use of unscheduled health care settings in the first few months of Aiden’s life was not piecedtogether by professionals resulting in a fragmented understanding about the level of support needed.-There was no professional curiosity about the mother’s new male partner. His presence in Aiden’s life wentun-assessed.-Case management frameworks used by Children’s Services lacked coherence. As a result of this, the casestepped up very quickly to being managed via a legal framework without apparent evidence to justify this1 Working together to safeguard children, Chapter 4, HM Government, 2018. Contents 1. Synopsis of the review: page 12. Process for conducting the review: page 23. Family composition & contribution to the review:page 24. Synopsis of relevant case information including keyepisodes: page 3 - 55. Findings & analysis – pages 5 to 175.1. The assessment & response by professionals to vulnerability & risk  5.2. Professional understanding about Aiden’s day to day experience  5.3. The use of information to support, safeguard & challenge  6. Conclusion: page 177. Recommendations: page 18FINAL VERSION   2     approach, back down to Child in Need, and then case closure. There was no consideration about an Early Help support package.  2. Process for conducting the review 2.1. On the basis of wishing to conduct a proportionate review the following steps were taken; - Following the incident in December 2019 a Rapid Review of known agency information was completed in early January 2020. The outcome of this Rapid Review raised a number of questions about the way in which agencies had worked together on the case and confirmed the need for a CSPR to be completed.  - An Independent Reviewer2 was commissioned in February 2020 to conduct the CSPR.  - A succinct multi-agency3 chronology was compiled using case details from those agencies that had most contact with Aiden and his family from September 2017 to December 2019, when Aiden was admitted to hospital. - Those agencies involved with Aiden also provided a report which was informed by their own internal records but also discussions with practitioners. This allowed each agency the chance to reflect on their involvement with the family and respond to any immediate and obvious learning and improvement opportunities.  - A multi-agency practitioner workshop had been scheduled, initially for March 2020, to examine the case from the perspective of those closely involved. However due to parallel proceedings taking longer than anticipated and then the Covid-19 restrictions a live video workshop was held in September 2020 instead. 3. Family composition & contribution to the review 3.1. At the time of the incident in December 2019 Aiden lived with his mother and her male partner, known as Adult A. The mother’s relationship with Aiden’s father ended during the timeframe under review. Aiden has an older female sibling who was living with her own father at the time of the incident; the mother had regular contact with her daughter. Contact arrangements between Aiden and his father had not been formalised and, at the time of the incident, were subject to tensions.  3.2. Seeking the views of family members was an important consideration for this review. Due to the lengthy Police investigation, it was not possible to make contact with the parents until these had concluded. The Covid-19 restrictions then complicated arranging anything face to face.   3.3. The Independent Reviewer spoke with Aiden’s father over the phone who expressed dissatisfaction with the Social Workers involved with Aiden at the time, citing communication by them as unhelpful and inconsistent; he was particularly unhappy about the way in which the use of the Public Law Outline (PLO) appeared to be thrust on them.                                                              2 Kevin Ball was commissioned as the Independent Reviewer. He is an experienced author and chair of case reviews and has a background of working in various children’s services settings in operational and strategic roles.  3 The following agencies contributed to this review:      -             Reading Children’s Services (Brighter Futures for Children)   - South Central Ambulance Service    - Thames Valley Police      - Royal Berkshire NHS Foundation Trust    - Reading Borough Council Legal Services    - YMCA    - West Berkshire Healthcare Foundation Trust     - Berkshire Women’s Aid    -             Local GP Practice       FINAL VERSION   3     He expressed satisfaction with the involvement of Midwifery and Health Visiting Services, commenting that they were helpful in providing advice and support.  3.4. The Independent Reviewer made multiple attempts to contact the mother to gain her contributions; no response was received to any messages left.  4. Synopsis of relevant case information including key episodes 4.1. Aiden’s mother experienced a difficult childhood due to her own parents’ substance misuse and mental health difficulties resulting in her experiencing significant trauma. 4.2. It is reported that Aiden’s father has a history of domestic abuse and alcohol misuse, has some mental health problems, and learning difficulties. These have not been verified as they fall outside of the scope of the review. 4.3. Prior to Aiden’s sibling going to live with her father (at nine months old) she was subject to a Child Protection Plan due to her mother’s mental health and concerns about the quality of care she was receiving from her mother. 4.4. Key episode 1: August 2017 to February 2018: In August 2017, at the time of registering the pregnancy with Aiden, the mother disclosed her involvement with Children’s Services to the Midwifery Service and her emotional mental health difficulties. These disclosures prompted a referral to the Specialist Midwifery Team that works with vulnerable pregnant women based in the Royal Berkshire Hospital. At the time the mother lived in YMCA accommodation and the father visited regularly.  4.5. In late September 2017 the Specialist Midwifery Team made a referral to Children’s Services. A home visit was then conducted by the Specialist Midwifery Team in early October. The Midwife advised the mother that a referral to Children’s Services had been made. This prompted a Single Assessment4 to be conducted by Children’s Services. 4.6. Records indicate that, whilst risks were identified, the situation was to be managed via the Child in Need5 framework with what appeared to be regular meetings being held. In November 2017 and January 2017, the Specialist Midwifery Team raised concerns with Children’s Services about it being managed under this framework, and that an assessment had still not commenced, and the mother’s parenting capacity with a new baby was unknown. During this time the mother was attending her scheduled antenatal appointments. 4.7. In February 2018 the Specialist Midwifery Team sent a further email to Children’s Services outlining risk factors including the fact that the mother had a previous child no longer in her care who was removed at nine months old, and expressing concern that a parenting assessment had not been completed in respect of this pregnancy. A Child in Need meeting a few days later – which was attended by the Social Worker, Health Visitor, YMCA and Midwife – raised concerns about the situation. Records indicate that a legal planning meeting was then held two working days later                                                              4 Single Assessment - Berkshire West Safeguarding Children Partnership procedures manual  5 Child in Need – Section 17 of the Children Act 1989 imposes a general duty on the Local Authority to safeguard and promote the welfare of children who are ‘in need’ and to promote the upbringing of children in need by their families by providing a range and level of services to meet those children’s needs. A child in need is defined as a child: i) who is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services; ii) or a child whose health or development is likely to be significantly impaired, or further impaired, without the provision of services; iii) or a child who is disabled.  FINAL VERSION   4     which determined that the threshold for initiating the Public Law Outline6 framework had been met; a number of other recommendations were made by Legal Services. 4.8. Aiden was born eight days later. A discharge planning meeting was held two working days after Aiden was born with a plan that Aiden and his mother would initially go to live with the maternal grandmother and receive support and then back to the YMCA after a few days. 4.9. Key episode 2: February to April 2018: The mother and father expressed upset about the situation now being moved in to the PLO framework; the YMCA complained about the way in which the situation had been escalated into legal proceedings. In these early days, on the whole no concerns were noted about the care Aiden was receiving. 4.10. In March 2018 the mother received a letter from Children’s Services outlining the PLO process and the plan was for the mother and Aiden to go into foster care for a parenting assessment. Records indicate that the Health Visitor made attempts to contact the Social Worker to discuss these issues but also sought advice from the Named Nurse for Child Protection with a view to escalating the issues identified. Also, in March funding requested by Children’s Services Panel for a parent/baby placement was refused due to the purpose not being clear and the request having no evidence base. A scheduled review meeting for the PLO process later in March was cancelled as the Social Worker did not attend, and it was only attended by the Solicitor and minute taker. At the end of March, a Strategy7 discussion was held due to concerns about the mother’s ability to care for Aiden; agreement was reached that the case should proceed to an Initial Child Protection Conference (ICPC)8. 4.11. In April 2018 an ICPC was held and Aiden was made subject to a Child in Need plan with the Chair noting ‘... there isn’t the evidence to say that Aiden is currently suffering significant harm or there are any safeguarding concern. The history is acknowledged, and it is recent, but there were other contributing factors towards that. The mother’s mental health has stabilised, she is in a new relationship and is back in contact with her mother. The family does need support, but this does not need to be done under a protection plan …’. The majority view in the conference was that the threshold for a Child Protection Plan was not met. 4.12. In May 2018 records refer to a PLO review meeting during which the mother and father agreed to a PAMS assessment9. A further PLO review was held in July where it was acknowledged that the process was being delayed due to assessments not starting. Child in Need meetings were also held, as were visits by Children’s Services and the Health Visiting Team under the Universal Partnership Plus programme. 4.13. In August 2018 the PAMS assessment was completed and concluded that the mother and father could meet Aiden’s needs in the short and long term and that no risks were identified during the assessment process. In turn, a                                                              6 Public Law Outline – case management framework for cases proceeding to public law management.   7 Strategy meeting - Berkshire West Safeguarding Children Partnership procedures manual  8 Initial Child Protection Conference – Berkshire West Safeguarding Children Partnership procedures manual  9 PAMS – Parent Assessment Manual Software is a branded assessment model specifically developed to assess parenting capacity.   FINAL VERSION   5     PLO review meeting held in September decided to step down the PLO process. Also, during this period, the mother, father and Aiden were given their own independent accommodation and moved out of YMCA accommodation. 4.14. Key episode 3: September 2018: Later in September two separate injuries to Aiden were reported; firstly, Aiden was taken to a Child Health Clinic with a small carpet burn on one ankle, and secondly, a few days later the father sought telephone advice from NHS 111 reporting Aiden having a fall and having a minor head injury. Only the first incident was reported to the Health Visitor, who followed it up during her next scheduled; neither incidents were reported to the Social Worker. Additionally, during a home visit, the Health Visitor reported the mother and the father had raised their voices between each other and the situation in the home was tense; appropriate advice was given at the time in response to the relationship tensions.  4.15. In November 2018, at a review Child in Need meeting, all professionals unanimously agreed for the case to be closed due to the positive progress made by both parents. A final meeting by Children’s Services was scheduled for December. At a nine-month developmental check in December 2018, with the exception of some slight delay to problem solving ability, no concerns were noted by the Health Visiting Service. These were later assessed to be within developmental range within a month following advice being given to the parents. 4.16. In February 2019 the Social Worker conducted a ‘goodbye’ visit. Aiden was reported as looking and presenting well, sleeping in his own room, and the home environment was clean and organised. 4.17. In March 2019 Children’s Services received an anonymous call from someone who lived in ‘the same block’ as the mother, expressing concerns about Aiden’s welfare; specifically, about the way he was dressed in the cold weather and the food he was being given. Whilst the call was judged malicious a Social Worker did visit the mother and no concerns were noted; the case closed. The Health Visitor was informed about this anonymous referral.  4.18. In April 2019 the Health Visiting Service stepped down their involvement to Aiden from targeted to universal service as there were no concerns.  4.19. In May 2019 a Child in Need Reviewing Officer (a post that reviewed cases recently stepped down from a child protection threshold to a Child in Need) recommended a further home visit be undertaken given the previous concern held by the local authority.  4.20. In October 2019 Aiden’s mother and father separated; they both attended a Police station and were argumentative about contact arrangements between Aiden and the father. At this stage the mother had started a relationship with Adult A. No further action was taken against the parents however a DOM510 was completed by the Police and the information was shared with Children’s Services. This prompted Children’s Services to agree an assessment was needed and the case being allocated. Later in October the mother saw the GP and expressed concerns about Aiden’s behaviour and possible ADHD. A follow up Health Visitor check was completed during which the mother expressed worries about not having contact with her daughter, some eczema was noted on Aiden and he appeared miserable; recent domestic incidents between her and the respective fathers of her children were also discussed. The change in Aiden’s presentation was reported back to the Social Worker.                                                              10 DOM5 – Domestic abuse risk assessment took used by the Police.  FINAL VERSION   6     4.21. In December 2019 the assessment was completed and the case was closed. Four days after the case was closed Aiden was taken to hospital with a significant burn to his abdomen, but also other injuries on his right forearm, hand and buttock. A Strategy meeting was convened resulting in legal intervention being taken to safeguard Aiden. 5. Findings & analysis 1. Following documentary analysis and discussions with practitioners, managers and designated post-holders there are a number of issues and themes that emerge. The following analysis focuses mostly on the three key episodes highlighted above and offers learning points for practitioners, managers, trainers and designated post-holders. The following areas were agreed as needing to be examined; - The response by professionals to vulnerability & risk - Professional understanding about Aiden’s day to day experience - The use of information to support, safeguard & challenge   5.1. The assessment & response by professionals to vulnerability & risk Prior to Aiden being born – Key episode 1 5.1.1. Statutory guidance states ‘… Understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by evidence available and underpinned by knowledge of child development …’. 11 5.1.2. When assessing risk from a safeguarding and child protection perspective, it can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e., situational risks, and those where there is less likelihood of effecting change and which are more historical and may be biographical in nature i.e., pre-disposing risks12.    5.1.3. For Aiden’s mother there were some considerable and known pre-disposing risk factors that formed part of her history; these included, - As a child herself, Aiden’s mother experienced significantly difficulty and trauma.  - Further to this, she experienced mental health difficulties, had a diagnosis of emotionally unstable personality disorder and had undiagnosed learning difficulties. - The mother had a period of time without accommodation and was homeless. - The mother had been involved in a series of abusive adult relationships. - There had been concerns about the mother’s care of her first child, who had been subject to a Child Protection Plan, and was no longer living with her.                                                               11 Working together to safeguard children, 2015 & 2018, HM Government  12 A model for risk assessment as proposed by Brearley in 1982, as cited in Risk in Child Protection, Calder, M., 2016, Jessica Kiingsley.  FINAL VERSION   7     5.1.4. Aiden’s father also had some known and pre-disposing risk factors; a history of domestic abuse, mental health problems, alcohol misuse and undiagnosed learning difficulties. Aiden’s father confirmed some of these issues during discussion. 5.1.5. Based on these known and considerable pre-disposing risks it is argued that there was ample and significant evidence to warrant a rigorous formal pre-birth assessment of both parent’s abilities to care for a new baby – as set out in local safeguarding procedures13. Given the care of Aiden’s older sibling being transferred to her father at nine months of age there was no evidence that the mother was able to effectively care for a child in the medium to long term; knowledge about her parenting skills was confined to a set of facts that her capacity had recently been considered inadequate and that a child in her care had been subject to, or likely to suffer, significant harm.  Learning point: The impact of experiencing significant trauma, adversity and loss as a child, such as the mother had in this case, is likely to contribute to parenting capacity being compromised14. Learning point: Findings from Serious Case Reviews often highlight multiple risk factors being a contributory factor to the death, or serious harm, of a child. It is important to thoroughly assess each risk factor to better understand which needs might be associated with which risks.  5.1.6. A Single Assessment conducted by Children’s Services in September 2017 (at 17 weeks gestation) lists the concerns and a number of strengths and makes several references to further assessment being needed. It is not recorded whether this assessment benefitted from the contributions of other professionals and agencies – review of the document suggests no contributions by other agencies at-all. The opening statements refer to the unborn baby as ‘it’ twice, which is far from being a child centred way of describing a child but potentially reflective of a view that the unborn child had a lower status and priority. The management decision endorses the need to formulate a Child in Need plan ‘… to ensure the welfare of the unborn and ensure that the baby will be adequately safeguarded when born.’15 There is no consideration of other options being explored or the type of further assessment needed. There is no evidence to indicate a formal, holistic, and multi-agency pre-birth assessment took place after the Single Assessment had been signed off. No reason for this has been provided. Children’s Services now have a dedicated Early Help Pre-birth Team (since June 2019) that provides a dedicated service which aims to reduce the number of new-born removals and reduce the number of fostering placements. 5.1.7. One of the clearest findings that emerges from information is the intention by Children’s Services to use of the Child in Need framework to guide assessment and interventions during the pregnancy, and the concerns that this raised amongst other professionals involved, specifically the Specialist Midwifery Team. Worries about the timeliness and pace of this approach emerge and were appropriately challenged by the Specialist Midwifery Team, but to no effect.                                                               13 Pre-birth procedures - Berkshire West Safeguarding Children Partnership procedures manual  14 i) Does the past predict the future? Reder, P., in Studies in the Assessment of Parenting, Reder, P., Duncan, S., & Lucey, C., Routledge, 2007 and ii) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003 – 2005, HM Government.  15 Reading Single Assessment, September 2017, Reading Borough Council.  FINAL VERSION   8     5.1.8. The Child in Need Plan16 formulated in November 2017 by Children’s Services during the pregnancy provides very limited commentary or evidence of any professional curiosity or questioning through assessment activity about how the mother had experienced parenthood with her first child. Statements made in the section ‘what are we worried about’ fail to capture and offer an analysis of what the issues might actually mean in relation to parenting capacity and the experience of a young infant. For example, the statement ‘the mother had a diagnosis of emotional unstable personality disorder’ is not interrogated or analysed in terms of what this might mean for attachment and bonding with a new born child. Each of the ‘worries’ statements inherently refer to issues that carry complexities – and which could have a profound impact on the ability of a vulnerable adult to safely care for a vulnerable child but which are not explored. Learning point: Linking and analysing statements of fact about a parent/adult with what impact the issue may have on a child’s safety and welfare is a key task for those practitioners responsible for assessing risk to children. Ensuring records reflect this thinking process is important for future workers or colleagues to understand. Management oversight and scrutiny of such assessments and judgements is critical in order to promote clear thinking, a clear rationale for decisions and effective safety planning. 5.1.9. The above finding possibly reflects a high degree of over-optimism – at an individual worker level, but given the management endorsement of the assessment and Plan, it also potentially reflects a more systemic and cultural issue. In another relatively recent Serious Case Review (I17, completed in January 2019) conducted for Reading Local Safeguarding Children Board and which looked at the period March 2014 to June 2016 significant findings were made about the quality and effectiveness of the Child in Need framework, systems and processes being provided in Reading at that time. As well as a series of learning points one of the recommendations was ‘The LSCB to seek assurance from Children’s Social Care that the issues highlighted in this report are being addressed in a robust and timely manner; particularly in relation to the application of Child in Need procedures, and including the use of history to inform assessment and planning, the quality of assessments especially of those situations where children are living with domestic abuse, the recognition of risk, the coordination and effectiveness of multi-agency meetings to safeguard and protect children’. The I17 review referred to the findings of the inspection conducted by Ofsted in May 2016 noting embedded and anchored practice in this area due to demands and pressures.  5.1.10. This review examines the timeframe from September 2017 to December 2019; a period of time which has some overlap with the I17 review. It would therefore be reasonable to conclude that many of the findings made in the I17 review regarding the quality and effectiveness of the Child in Need system and processes will be repeated findings for this review. In that respect there is limited value in reciting the issues; however, there is value in seeking a commentary about progress on the specific I17 review recommendation, given the timeframe for this review extends into a period of time when one might reasonably expect to begin to see improvements being made. 5.1.11. Commentary submitted to the review refers to amended Child in Need procedures being introduced in 2020, increased visiting frequency and review for children subject to Child in Need Plans, a shift in emphasis on step-down arrangements, increased expectations regarding the use of chronologies alongside changes in management oversight and regular audit activity. It is noted that these activities have been implemented in early 2020, some 12 months after the conclusion of the I17 review was finalised. It is also noted that there have been three different Directors of                                                              16 Reading Child in Need Plan, November 2017, Reading Borough Council. FINAL VERSION   9     Children’s Services in post during this timeframe. Given the embedded and anchored practices noted in the I17 review, but the very recent introduction of revised Child in Need arrangements which have also occurred alongside the challenges of Covid-19 for all workers, it will be critical for senior leaders in Children’s Services to maintain their oversight of children that hover around the Child in Need threshold, considering need but also risk. 5.1.12. Despite attempts to escalate their concerns, the Specialist Midwifery Team do not appear to have received a response from Children’s Services on at least two separate occasions (January & February 2018). Given the ongoing Child in Need meetings, a clear lack of formal assessment work taking place, and an advancing pregnancy the response by Children’s Services appeared to lack any sense of urgency and the assessment and response to vulnerability and risk was not satisfactory. Of additional interest, it is noted that minutes of Child in Need meetings were not received by the Specialist Midwifery Team. The increasing attempts to challenge and escalate by the Midwifery Service warranted greater authority and pace; there is no evidence to indicate this happening. Reasons given for this include some uncertainty by those that could have escalated about the best route for achieving it, and a new post-holder in the Named Midwife role not being fully familiar with the process.  5.1.13. A further opportunity may have been missed inasmuch that, despite it being an agreed action recorded in the Health Visiting records following a Child in Need meeting in January 2018, there is no indication that a referral was made to the Perinatal Mental Health Service by either the Specialist Midwifery Team or Health Visiting Service. Further interrogation of this highlights that as the Health Visitor saw the mother just before the birth and no concerns were observed or reported the sense of importance for such a referral was not apparent, which accounts for the referral not being made. It is impossible to know whether, had this referral been made and the mother engaged with it, whether it would have revealed any underlying concerns that might have been supported. 5.1.14. Records relating to the initial legal planning meeting held in February highlights appropriate recommendations being made by Legal Services, such as further assessment work, convening a Strategy Discussion and to proceed to an ICPC, and assessment of extended family members. Legal Services have noted that it had been too late to conduct a comprehensive pre-birth assessment at that stage. Records indicate that the follow up Legal Planning meeting in March was completely ineffective. Not only had the Mother been poorly supported to attend the meeting (including without having legal representation) but there had been no agreement from the Children’s Services Panel to fund placements – despite three attempts to gain a decision – due to no assessments being completed. Altogether, this reflects a wholly dysfunctional approach to managing the case, originating with a lack of planning and preparation for assessment work at an early stage of the pregnancy and which appears to have been exacerbated as time passed by the lack of adequate management support, oversight and guidance. The desire to have some sort of protective framework around the new born baby appears to have been based on unassessed need and unassessed risk. Following Aiden’s birth – Key episode 2 5.1.15. As noted above, there were opportunities pre-birth for a more collective and robust response by professionals. Following Aiden’s birth, records indicate that the response by Children’s Services lacked coherence. 5.1.16. In March 2018 a Strategy meeting took place due to concerns about the mother’s care of Aiden. The Health Visiting Service have reported that it was unclear why a Strategy meeting was convened given that the mother’s care of Aiden had been judged satisfactory. The underlying concerns appear to stem from an anxiety originating from the Health Visiting Service that the case justified being managed via a child protection framework rather than a Child in FINAL VERSION   10     Need framework. This was based on their knowledge that the current approach, via the Child in Need framework had not been defined and did not appear to be robust.  5.1.17. Positives were noted during this Strategy meeting relating to the progress the mother had made in her recent life; namely, i) she had been working well with professionals, ii) had been living in YMCA accommodation for over a year and demonstrated self-care and care of her living environment, iii) had stabilised her mental health with the support of medication, iv) had improved her relationship with her own mother and did not require ongoing support from Adult Services, v) had completed a course with Berkshire Women’s Aid, vi) and contact arrangements between her and her first child had settled somewhat. It appears that the decision to proceed to an ICPC was based on the fact that the mother was refusing to co-operate with the Children’s Services’ plan of her being assessed via a parent/baby placement and engage with a support package. The issues listed under the ‘what are we worried about’ section all relate to the pre-disposing factors outlined above in section 5.1.3. No immediate and obvious situational risk factors are detailed. 5.1.18. The underlying cause of dissatisfaction by the mother was the fact that the case had been moved into the PLO framework before its time and not wanting to go into a parent/baby placement to be assessed. Based on the presenting evidence and lack of formal assessment to date, but also the considerable positives that had been noted in the mother’s recent life, this does not seem an unreasonable response. The more conventional and measured route would have been having Aiden and his family subject to more stringent assessment, monitoring and intervention arrangements via a multi-agency Child Protection Plan rather than taking the most interventionist and reactive route via legal proceedings. Research17 notes that ‘… care proceedings cannot be brought until after birth, when the foetus gains ‘personhood’ within the law. For the same reason … [authorities] … do not generally have the right to compel mothers to engage with child protection services during pregnancy, although voluntary engagement is encouraged. However, in the absence of effective assessment and support at a timely point in pregnancy, intervention at birth is likely to be poorly planned and risks instability for the new baby and huge distress for all family members …’. 5.1.19. In examining the professional assessment and response to vulnerability and risk it is helpful to consider the different perspectives of those involved with Aiden, his mother, father and Adult A. 5.1.20. From the Health Visiting Service perspective, the Health Visitor had known the mother since the birth of Aiden’s older sibling and was aware of the mother’s history and vulnerabilities. A targeted ante-natal family health assessment was completed which identified that Aiden would benefit from a Universal Partnership Plus service from the Health Visiting Service. The Health Visitor attended Child in Need meetings and scheduled additional visits based on the additional offer. Both parents engaged with these visits and followed advice.  The Health Visiting Service have noted that both parents were regularly accessing child health clinics, out of hour’s services and the GP for issues about Aiden’s health. Review of the chronology highlights records of 16 different attendances from April 2018 to November 2019; on the whole these attendances by the mother on behalf of Aiden seem appropriate. However, when placed alongside the mother also accessing health services (mostly her GP) a similar number of times for herself there is an argument to suggest it reflected someone that was struggling to manage health related issues – whether for herself or her child. Although this may not be a risk factor to a child by itself, it is information that could usefully be used by                                                              17 Pre-birth assessment and infant removal at birth: experiences and challenges, p.4, Nuffield Family Justice Observatory, 2019.  FINAL VERSION   11     professionals to be additionally curious with the mother but also contribute to an overall assessment of parenting capacity. There is no record that this information was used to contribute to any assessment work taking place during this time.  5.1.21. Separate observations by the Health Visitor and the Specialist Midwifery Team at the maternal grandparent’s home during March 2018 were that the mother appeared to be managing Aiden’s needs well and was receiving support from her partner. It was recorded18 in March 2018 that the mother was interacting and bonding well with the baby. These separate accounts reflect a professional that has engaged well with a mother and father, noticed changes in a child’s presentation and responded appropriately.  5.1.22. From the YMCA perspective, the mother was initially living in the YMCA and as such she was receiving a significant amount of professional support; she had benefitted from support from them for over 12 months and made good progress. They have noted that ‘… risk was assessed during numerous multi-agency meetings and support planning and risk assessment by the YMCA. At the time of residency … the mother was in a stable relationship with Aiden’s biological father. There was no evidence or history of drug or alcohol or other misuse …’19.  5.1.23. From the perspective of Berkshire Women’s Aid, they had worked with the mother for over two years and she had engaged well in the programme. Berkshire Women’s Aid have reflected that they should have made contact with the Social Worker following the mother completing her programme in order to fully ensure safety planning was as robust as it could be.  5.1.24. From a Children’s Services perspective, the Service had worked with the mother during the time when the older sibling had transferred from the mother’s care to the father. Critically however, the mother and Aiden had eight different Social Workers between February 2018 through to October 2019, and who were managed across the time period by three managers. One Social Worker was consistent for nearly two months up to, and post, birth. Two Social Workers were from a duty system and therefore did not hold case responsibility but undertook visits to check on welfare, and another Social Worker just chaired a Child in Need meeting. This is a stark finding but one that helps us understand and contextualise why events occurred as they did. It highlights the lack of continuity and therefore the inability for any one worker to meaningfully form a trusting relationship with the mother and father, and assess their parenting capacity. It also demonstrates a lack of consistent management oversight and goes some way to our understanding about the factors that contributed to the approach to case management discussed earlier. 5.1.25. Exploring these different perspectives is an important part of trying to disentangle and understand the professional response to the mother at the time of her pregnancy with Aiden and then the immediate few weeks following his birth. From a system thinking perspective the concept of emergence20 is relevant.  Emergence is a key property of complex systems – of which a safeguarding network of professionals is one example. The strength of a complex and self-organising system such as a network of professionals across a safeguarding partnership can often be tested against its ability to respond to emerging issues which cannot be controlled, predicted or easily managed. Emergence as a concept is therefore relevant as it allows us, often with the benefit of hindsight, to better examine                                                              18 Combined chronology generated for the review, various entries around March 2018.   19 YMCA submission to the review, January 2020.  20 Seel, R., Emergence in organisations, 2006.  FINAL VERSION   12     system weaknesses – rather than purely concentrating on the efforts, or errors, of individual practitioners. The emergent features of Children’s Services during this time, such as high staff turnover, inconsistent management oversight, and challenges in the quality and effectiveness of assessments and interventions reflects the absolute need for strong management and quality assurance mechanisms that can effectively respond to all types of new and emerging information. Aiden, the mother and father, and other professionals experienced the emergent symptoms generated by Children’s Services at that time. Learning point: Consistency and continuity of worker with children and families is important. It allows trusting and meaningful relationships to develop and supports the Social Worker, as an agent of change, to monitor developments and shifting family dynamics. It also provides the worker with an opportunity to notice negative changes that may impact on the safety and welfare of a child/children.  5.1.26. It is possible that there were elements of over-optimism from the Health Visiting Service, only seeing the positive aspects of the mother’s parenting following Aiden’s birth; however, this has to be balanced with knowledge that the Health Visitor did raise concerns about the mother’s first child but also the change in Aiden’s presentation in October 2019, thereby suggesting a sound grasp about possible, or actual harm. If there were elements of over-optimism these views would likely have been formed unconsciously because of the mother being in receipt of substantial support from the YMCA and supported accommodation – which is clearly a very different set of circumstance to living independently with her partner. When the PAMS assessment was completed in August 2018 it confirmed the views of the Health Visiting Service that the parenting was good enough at the point when Aiden was being jointly parented by the mother and father, but undermined the views of Children’s Services. This would have further highlighted the evidential discrepancy between the Health Visiting perspective and Children’s Services perspective. Children’s Services have noted that during a Child in Need meeting in March 2018 ‘Professionals involved complain about the Local Authority’s approach to safeguarding Aiden given that in their view [the mother] has made positive progress and is being supported by [the father] …’. The test of parenting capacity was surely most needed when support services began to step away and the mother and father were acquiring greater independence from professionals.  Learning point: Learning point: Revising, or at very least re-visiting, initial assessments, thoughts and feelings about a child’s circumstances and safety is an important concept for all workers to be open to. The failure to review or to dismiss new information is often cited as a contributory factor in serious cases of child abuse. Ensuring that regular, good quality and reflective supervision is available will help workers develop these critical thinking skills21. 5.2. Professional understanding about Aiden’s day to day experience 5.2.1. Statutory guidance states that a ‘… child centred approach is fundamental to safeguarding and promoting the welfare of every child. A child centred approach means keeping the child in focus when making decisions about their lives and working in partnership with them and their families. … Anyone working with children should see and speak to the child; listen to what they say; take their views seriously; and work with them and their families collaboratively when deciding how to support their needs …’.22                                                               21 The oversight and review of cases in the light of changing circumstances and new information: how do people respond to new (and challenging) information? Burton, S., 2009, C4EO.  22 Working together to safeguard children, 2018, HM Government. FINAL VERSION   13     5.2.2. Following Aiden’s birth, the consistency of the Health Visitor in his life allowed the opportunity to gain a sense of perspective about his day-to-day experiences, albeit on an occasional basis when seen during scheduled appointments. Additional support from a Nursery Nurse helped form this picture. Appropriate equipment for a new baby was noted in the accommodation and both parents had engaged well with professionals. Observations of Aiden having skin to skin contact at the new birth visit were noted, he was seen at all visits and he was seen to be adequately cared for.  Both parents were seen to handle him with warmth. The Health Visiting Service have also noted that ‘… there is no evidence that Aiden’s development was delayed or that there were concerns about his growth whilst he was on a child in need plan and being regularly reviewed by those professionals ... Aiden’s weight and development were monitored regularly by the Health Visitor and Nursery Nurse and no concerns were noted until the Health Visitor made a home visit in October which took place after two domestic incident forms were received relating to the family ...’. They go on to note ‘… the Nursery Nurse conducted a targeted home visit for Aiden’s 9-12 developmental review and all domains of his development were assessed as within normal limits apart from problem solving skills. Advice was given to the parents on how to play with Aiden to assist in the development of this area. A follow up review was completed a month later and Aiden scored within the normal range for problem solving skills. It is not unusual for children to reach developmental milestones at different rates. Aiden continued to grow within normal limits …’.23 Reflections from the Health Visiting Service support a view that ideally, in future similar situations, a joint visit would be best practice allowing the Nursery Nurse to focus on the developmental issues and a Health Visitor to take a more holistic view considering the complexities of risk, environmental and relational factors. Clearly Aiden was not of an age where he could verbally communicate but it is clear that the Health Visitor noticed a change in his behaviour in October 2019 when he was reported as looking miserable. This happened around the time of the relationship between the mother and father breaking down in October 2019. However, this change in behaviour was based on the last visited conducted in April 2019; due to him being stepped down to a universal service, there had been no Health Visiting input between April and October 2019. 5.2.3. When the mother entered into a new relationship with Adult A in October 2019 the observed concerns about the mother’s hostility and Aiden’s presentation were reported to the Social Worker. It was noted that, with the benefit of hindsight, the Health Visitor never had the opportunity to see the mother on her own; this may have offered an opportunity for the mother and Health Visitor to discuss relationships. 5.2.4. These insights provide our only understanding about what day to day life was like for Aiden, prior to his admission to hospital with the burns.  5.2.5. Review of the documentation from Children’s Services reveals a very adult focused set of facts, statements and commentary. With eight different Social Workers it would have been challenging to gain and report any perspective about Aiden’s day to day experiences over time. 5.2.6. Children’s Services closed their involvement in November 2018 (although a ‘goodbye’ visit was conducted in February 2019), and the Health Visiting Service stepped down the level of service from universal partnership plus (targeted) to universal in April 2019. Given this, knowing about and understanding Aiden’s day to day experiences                                                               23 Berkshire Health Care Foundation Trust, submission to the review.  FINAL VERSION   14     from April 2019 onwards would have relied on the mother’s accounts as there were no professionals consistently involved in Aiden’s life.  5.2.7. Records indicate that there was no consideration about stepping down involvement from Child in Need to Early Help; it appears decisions were made to simply close involvement. Given the mother’s history and the interventions attempted during Aiden’s early months, the offer of an Early Help support package seems entirely appropriate. No clear explanation can be provided as to why an early help approach was not considered or any consideration that the case had gone from potentially needing a Child Protection Plan (but then not deemed as meeting the threshold) to then stepped up into the PLO framework and then stepped down to Child in Need. It is also not clear about the rationale for the threshold for Aiden potentially needing to be subject to a Child Protection Plan was not reached, yet subject to the PLO framework – which has the same threshold criteria regarding actual or likely significant harm.  5.3. The use of information to support, safeguard & challenge    5.3.1. Statutory guidance24 in place at the time refers to the need for effective information sharing practices between professionals and local agencies. Key episode 3 highlights three separate issues in September 2018. Of interest to this review is the professional response to this information.  - In respect of the carpet burn, the Health Visiting Service have noted ‘… At one child health clinic attendance [in September 2018], when Aiden was 6 months old, it was noted that he had an unusual mark on his ankle which father said was due to a carpet burn. There is no evidence in the … records that this was investigated and the Berkshire Bruising Protocol discussed or invoked.  The bruising protocol should have been invoked or advice taken from a safeguarding named professional and this may have provided professionals with insight into risk factors. This has been raised with the Health Visiting Head of Service ...’25. The finding has resulted in the professional Lead for Safeguarding sending a copy of the bruising protocol to all Health Visiting staff with a reminder that any bruise or suspicious mark on a baby must be discussed with a member of the Safeguarding Team and a referral to the Paediatrician and Children’s Services made if required. In addition to this, although the Health Visitor completed a home visit following this incident there is no record that the information was shared with the Social Worker. The Health Visitor cannot recall why it was not shared with Children’s Services or the reason for the bruising protocol not being followed. Staff were also reminded that any mark should be clearly documented in the record and the rationale for the decision about whether or not a referral was made must be recorded. - In respect of the alleged fall and minor head injury in September 2018 and the problems with notifications to Children’s Services and the Health Visiting Service, it has since been discovered that NHS111 had an incorrect e-mail address; this has now been rectified. - In respect of two domestic abuse incident notifications to Children’s Services from the Police in October 2019 about two separate incidents involving Aiden’s father and the mother, the notification system worked well. Information was shared with Children’s Services which, in turn, was shared with the Health Visiting Service. It allowed the Health Visiting Service to exercise some curiosity during a home visit. Records indicate that this was the first time that the Health Visitor knew about the end of the parental relationship, but which prompted a home visit. This was a positive response to new information. During this visit concerns were noted about Aiden’s                                                              24 Working together to safeguard children, 2015, HM Government.  25 Berkshire Health Care Foundation Trust, submission to the review. FINAL VERSION   15     presentation and behaviour, but also the mother’s defensive and aggressive behaviour; Adult A was noted to be present in the home. The Health Visitor appropriately shared this information with the Social Worker and also made a plan to visit the family again. Again, this was an appropriate response to the circumstances, especially given the known history.  5.3.2. One further point is worth examining in respect of the anonymous referral made in March 2019. The response by Children’s Services was appropriate, in that it prompted a home visit to assess the concerns raised. Whilst it was judged as malicious, it will be important for future practice to attempt to gather sufficient evidence to disprove the allegation or concern and that there has been a deliberate act to deceive. The Safeguarding Partnership may wish to seek assurance that sufficient credence is given to anonymous referrals especially on cases already open. 5.3.3. During a home visit by Children’s Services in October 2019 Adult A was present. He was observed being appropriate with Aiden however the record of this Single Assessment (in response to the notification from the Police regarding the domestic disputes between the mother and Aiden’s father) highlight that there was no questioning or curiosity about Adult A. The outcome of the visit is case closure, but this did not receive management sign off until December 2019. There is no indication that it might be worthwhile seeking consent to make further enquiries about the new male in the mother’s life to ascertain if he presented a risk to Aiden and no management oversight that this might be an avenue worth exploring. 5.3.4. Information submitted indicates that records of Child in Need meetings were not shared with other agencies, nor was the outcome of the PAMS assessment. The lack of sharing of Child in Need records by Children’s Services has been cited as a systemic issue by the Health Visiting Service. Although this was raised as a concern by the Health Visiting Service, advice was appropriately sought, and the Social Worker was contacted, there was no follow through or response.  It has been noted that the Health Visiting Service were understaffed at the time and this may have impacted on their capacity to continue chasing for these records. Although verbal advice was given, there was no written evidence within the Health Visiting Service records that Aiden and family had been discussed by the Health Visitor in safeguarding supervision. Learning point: Actions agreed verbally during either formal or informal supervision should always be recorded, especially those which concern safeguarding issues. Learning point: The minutes of meetings are an important part of the overall case management record and are vital if there is a change of personnel due to sick leave or staff leave. Minutes should confirm what has been discussed and what the actions are for each professional between meetings. These should be shared and responded to in a timely manner to ensure pace is maintained with case management.  5.3.5. Records indicate that the emergency Ambulance crew did challenge the mother about her version of events and the burns Aiden suffered whilst on the journey. This information will form part of the Police investigation.  5.3.6. The chronology highlights the mother’s unscheduled use of the out of hours GP service, NHS 111 and walk-in-clinics with Aiden. These appear to be for minor issues. On one occasion the mother contacted NHS 111 and then attended the A&E Department. The A&E Department appropriately notified the Health Visiting Service of the attendance but contained only limited detail. However, and potentially of greater significance, the GP Practice have noted ‘… There is evidence that mother accessed services in an often ad-hoc manner. Notification of all contact with unscheduled care settings was shared. There is no evidence from the records that mother’s mode of accessing services was never challenged, [the mother’s] … A&E attendances were challenged in 2017 and tried to be addressed in primary FINAL VERSION   16     care by offering routine weekly … appointments to discourage from attending A&E, however … on balance, it could be assumed that the volume of contacts with health, especially unscheduled care, is far in excess of the norm for patients who do not have complex health needs … [the mother] accessed A&E, Out of Hours and Walk in Centre a few times  but [Aiden] was not flagged up as a child of concern at the time as was not on any child protection plans ...’.26 As noted above, information about frequent attendances at health care settings would have usefully contributed to an assessment of parenting.  Triangulating this information with known circumstantial facts i.e., the reduction in levels of support following transitions would have been useful.  5.3.7. For the purposes of safeguarding children there is often merit in being alert to patterns of repeated behaviour from parents. It is often only by building a picture over a period of time that it is possible to identify an emerging issue that may impact on the ability of the parent to keep a child safe or provide adequate care. The recognition and then sharing of such information by all professionals that come into contact with children is therefore important. There is no indication that the pattern of the mother using unscheduled care settings in respect of Aiden, whether with good and naive intent or otherwise, was recognised or challenged. During this time period, had information been submitted, Children’s Services as the lead professional agency, could then have determined the best course of action. Given the mother’s history of mental health difficulties this could have created an opportunity by all to add to the assessment work that should have taken place. As Aiden was not subject to a Child Protection Plan and was not a Looked after Child, the CP-IS notification system would not have recognised him and no notification would have been made. Learning point: Research27 notes ‘… Chronologies provide a key link in the chain of understanding needs/risks, including the need for protection from harm. Setting out key events in sequential date order, they give a summary timeline of child and family circumstances [or those of an individual using adult services], patterns of behaviour and trends in lifestyle that may greatly assist any assessment and analysis. They are a logical, methodical and systematic means of organising, merging and helping make sense of information. They also help to highlight gaps and omitted details that require further exploration, investigation and assessment …”. Chronologies can be used on a single or multi-agency basis and can support assessment and risk management work.   5.3.8. Following Aiden being admitted to hospital in December 2019 with burns and injuries it is evident that there were concerns about the management of the case and strategy for responding to the incident. The Royal Berkshire Hospital ‘… challenged the Local Authority around the legal status of the case … disagreed that this case could potentially go to Initial Child Protection Conference and advised that Aiden had suffered significant harm and questioned why the Joint legal team had not been involved which had been an action at the initial strategy meeting ...’28. These concerns were appropriately escalated to the Children’s Services Service Manager, the Associate Chief Nurse Safeguarding and Mental health at the Hospital, who in turn escalated to the Director of Children’s Services and Deputy Director of Children’s Services. By this time records indicate that the original decision to proceed outside of a legal framework had been over-turned and that the matter would proceed using legal intervention. Although challenge and escalation were needed, this is a positive example of a robust and timely intervention by one agency to another                                                              26 GP Practice, submission to the review.  27 Practice guide to Chronologies, 2010, Care Inspectorate, and the National Risk Framework to Support the Assessment of Children and Young People, Scottish Government.  28 Royal Berkshire NHS Foundation Trust, submission to the review. FINAL VERSION   17     at an appropriate senior level. It appears that a second challenge was directed to the Health Visiting Service by the Royal Berkshire Hospital in regard to some concerns noted in hospital about Aiden’s development and that the issues could have been noticed and responded to earlier. This challenge has to be viewed as a healthy example of professionals that are child focused. It is important to note in response to this challenge that Aiden’s health and development had been carefully monitored whilst he was under a targeted health visiting service and were within normal limits. When the Health Visitor later visited following a domestic incident, she noted a concerning change in Aiden’s presentation and appropriately reported it to the Social Worker. 5.3.9. From a Police perspective they shared information about the domestic incidents they attended in October 2019. These incidents concerned the break-up of the relationship between the mother and father, verbal arguments and Aiden seemingly being used as a form of control between the two parents. These issues were appropriately recognised by the Police as a potential child protection matter and information was shared with Children’s Services and the Health Visiting Service. 6. Conclusion 6.1. This Child Safeguarding Practice Review has taken a proportionate approach to examining the professional contact with a young child prior to him suffering significant burns and other injuries. It has built on the finding of a Rapid Review conducted by the Safeguarding Partnership and gained additional information from those agencies that were involved with him and his family. It has benefitted from the contributions of practitioners. Aiden’s father offered some thoughts to the review; however, Aiden’s mother did not engage with the process.  6.2. The review has made a number of findings but also captured areas for learning and improvement; findings include;  - There were a number of pre-disposing risk factors in the mother’s history that warranted a thorough assessment of her capacity to parent a young infant, prior to his birth. This assessment work did not take place despite Midwifery and Health Visiting Service repeated requests of Children’s Services. Factors that contributed to the assessment work not happening in a robust way included multiple changes in Social Worker, which resulted in a lack of continuity of assessment work, and over-optimism.  - The mother and father’s parenting capacity was initially assessed by health practitioners as being competent and sufficiently meeting the child’s needs; prior to the child’s birth the mother had been in receipt of considerable support for her own needs, and the impact of the transition from high support to greater independence and what this might mean for her parenting a new born child, was not fully recognised. - Information which began to emerge that might have suggested the mother and father’s parenting capacity was weakening, for example the high use of unscheduled health care settings, was not pieced together and resulted in a fragmented understanding about the level of support needed. This, alongside her worsening relationship with the child’s father, contributed to the child’s home life and experience deteriorating.  - There was no professional curiosity or assessment work completed about the mother’s new male partner.  - The frameworks used by Children’s Services to manage the case lacked coherence, and appear to have been based on very limited assessment work being conducted. Consequently, the case stepped up very quickly to being managed via a legal framework, back down to Child in Need, and then case closure. There was no consideration about an Early Help support package.  6.3. The report concludes with a number of recommendations for the local Safeguarding Partnership.  FINAL VERSION   18     7. Recommendations 7.1. Those agencies that have participated in this review and submitted single agency reports have had the opportunity to develop single agency action plans. The following recommendations are for the multi-agency safeguarding partnership; 1. To ensure the learning from this review is disseminated across the multi-agency Safeguarding Partnership to practitioners and managers.  2. To seek assurance that the actions identified by each partner agency, as a result of this review, have been managed, implemented and embedded in a timely manner. 3. The Safeguarding Partnership to determine whether there is merit in undertaking a focused and specific audit on open cases where anonymous referrals are made, to ascertain the quality and effectiveness of the assessment and response, and confirmation that evidence is gathered to disprove the concern/allegation and there being a deliberate attempt to deceive.  4. The Safeguarding Partnership to determine whether there is a need for a focused multi-agency audit exercise which interrogates how thresholds are applied by Children’s Services in cases where there are concerns about unborn children, and which are referred to Children’s Services by partner agencies. The audit should consider the quality and timeliness of the referral, how case history/chronological information is used, the timeliness of any risk assessment and safety planning activity (including the use of legal advice and legal frameworks), the presence of objective, multi-agency and child focused decision making (as opposed to the presence of bias and over-optimism), and the effectiveness of how well any professional disagreements or escalation are resolved. It should also examine the quality and effectiveness of any step-up or step-down activity during the time-frame being audited. The audit should cover from the point the pregnancy was booked by the mother through to six weeks post birth.  5. The Safeguarding Partnership to raise the profile about the need for all practitioners to be professionally curious about male associations with vulnerable women, especially where there is a child or children in a household. 