Summary of a review into the serious injury of a 7-month-old baby. Child W was taken into care on an emergency order following the incident and mother's partner was arrested on suspicion of assault. Before Child W was taken into care, family had made frequent visits to both GP and Accident and Emergency with concerns about Child W's health. Maternal history of: domestic abuse, depression, non-attendance at appointments for herself and her children and providing inconsistent information to professionals. Mother's partner had a history of: alcohol misuse and anxiety related illnesses. Identifies learning, including: agencies need to be more proactive to fulfil their safeguarding role; professionals need a wider understanding of the significance of injuries in young babies; agencies working with families should routinely enquire about and challenge adults where risks emerge about living arrangements, relationships and care; management and recording of strategy meetings needs to be consistent; communication within and between NHS agencies needs to be clearer; and there needs to be a way for agencies to flag known risks posed by adults without convictions.
      
 Title:  Executive summary of the serious case review in respect of Child W. LSCB: Manchester 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.                                    Executive Summary of the Serious Case Review in Respect of Child W    MSCB Independent Chair: Ian Rush     This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 30th September 2013. Page 1 of 8 1. Introduction  1.1 This Executive Summary presents the findings of a Serious Case Review of the actions of agencies that had contact with Child W and family. The review was completed to learn lessons to improve the way in which agencies work both individually and together to safeguard and promote the welfare of children.  1.2 Child W was taken into care on an emergency order aged seven months when examination showed a serious assault and a number of unexplained current and historical injuries.   1.3 The Chair of Manchester Safeguarding Children Board, Ian Rush, agreed that a Serious Case Review should be held. This was because of the severity of the assault to Child W and the history of a series of examinations by different NHS professional staff from when the baby was 12 weeks old.  1.4 The Serious Case Review was conducted in accordance with government guidance Working Together (2010) which expects Safeguarding Children’s Boards give consideration to conducting a Serious Case Review where: ‘Abuse or neglect of a child is known or suspected and the child has died (or has been seriously harmed) and there is cause for concern as to the way the authority, their Board partners or other relevant persons have worked together to safeguard  the child’.  1.5 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. Page 2 of 8 2. Process of the Review  2.1 As required by Working Together (2010) MSCB appointed an Independent Panel Chair (Mike Tarver) and an Independent Report Author (Hester Ormiston) for the Serious Case Review (SCR). Both Mike and Hester have extensive experience of child protection in practice as well as more recent experience chairing and writing overview reports for serious case reviews.  2.2 A panel was asked to oversee the process of the SCR which comprised: • Detective Sergeant, Greater Manchester Police • Deputy Designated Nurse, NHS Manchester • Consultant Paediatrician,  Designated Doctor, NHS Manchester • Interim Head of Safeguarding, MCC Children’s Social Care,  • Project Team Manager, NSPCC, and • Independent SCR Panel Chair.  2.3 The Independent Author attended each panel meeting. The panel met seven times between September 2012 and March 2013.  2.4 The panel confirmed terms of reference at the first meeting and that the timescale should be from Child W’s birth until the date of being taken into care.   2.5 Agencies in Manchester were asked if the family was known to them and five were asked to prepare Individual Management Reviews which critically considered the role of their own agency and identified lessons learned.  The other agencies did not provide any information relevant to the SCR. Four neighbouring local safeguarding boards contributed background information on the adults living with Child W during the review timescale.  2.6 Each individual agency author was invited to attend panel to discuss their reports. As three NHS agencies prepared individual reports, the two NHS panel members prepared a NHS Commissioning Overview Report.  2.7 For most of the timescale of the panel, a decision had not been made about a possible prosecution making it inappropriate for any family member to be interviewed. Towards the end of the process the Crown Prosecution Service (CPS) made the decision not to prosecute and the care proceedings for Child W and half siblings concluded with the return of the children to MW at the end of May 2013.  2.8 MW agreed to meet with the Panel Chair and the MSCB Business and Performance Manager to discuss her views on how agencies could have provided services differently to herself and her children. MW found it distressing to consider with hindsight how MPW could have injured her baby. She also now realises that staff in the two hospitals should have managed Child W's care differently and that the child’s injuries ought to have been identified sooner. MW conceded during interview that the children were regularly left in MPW's care but she never suspected him of harming them during this period.  Page 3 of 8  3. Brief Summary of Events  3.1 Following the birth of Child W, the first three months of life were unremarkable. However from the age of three months, Child W was taken on 11 occasions to the general practitioner (one of these was to the Out of Hours service), seven times to Accident and Emergency at one hospital and once to another hospital. In one month, Child W had six visits to the NHS agencies.  3.2 There was a diagnosis of routine childhood illnesses on some occasions but the review has found that on two occasions Child W had unexplained bruises and in the later weeks of the timescale Child W had pin point rashes which may have indicated an underlying cause for concern.  3.3 During one of the hospital visits (when Child W was six months but at a different hospital from previous visits) a Consultant Paediatrician was not satisfied with the lack of explanation for a bruise and arranged for further tests and a multi-agency strategy meeting. The first meeting was inconclusive as there was no paediatric representative. A second meeting was held the next day.  3.4 The arrangements for both multi agency strategy meetings held at the hospital were not satisfactory. The second meeting was overly reliant on medical opinion and the baby was discharged home.  3.5 Two weeks later, Child W was taken back to the first hospital with continuing symptoms. The doctor arranged further tests and checked back to the tests completed before the strategy meeting. The tests and examination showed: • Child W had a bruise on the right lower back and a swollen and tender left foot. Examination also showed a red mark to the side of the lip, a torn fraenum and a laceration in the genital area.   This was recorded as an acute injury which was found to have fresh blood indicating a possible assault that had ‘happened today.’   • The historical skeletal survey showed compressed fractures to Child W’s left tibia two to four weeks old, and a possible chip to the bone of the left foot. When reviewed again the survey showed a healing fracture on the first metatarsal and healing fractures on the 2nd to 5th long bones in the foot.  3.6 Child W was taken into care following discussion at a strategy meeting when the injuries above were discussed. A further strategy meeting a week after the reception into care identified a further fracture to the left forearm bone.  3.7 During this timescale, Child W’s mother had been to the General Practitioner for herself 20 times and three times to Accident and Emergency Department at the hospital. Her partner had also been to NHS agencies a number of times. As part of this review it was found that he had a history of misuse of alcohol and some anxiety related illnesses.  3.8 The health visiting service had been appropriately provided and the staff team knew the family well from the birth and early childhood of Child W’s two half siblings. Page 4 of 8  3.9 Child W’s mother presented as a worried parent, who was not satisfied with the responses at times of the General Practitioner and at times the first hospital. She continued to take Child W for advice and diagnosis. However she also had a history of not attending appointments both for herself and for her older children and at times the information she gave was not consistent.  3.10 After the first multi-agency strategy meeting Children’s Social Care began completing a core assessment to identify any need for support or intervention. This was the first social care contact with Child W’s family.   4. Analysis  4.1 The individual agency reports gave the panel a different view of Child W’s mother. Part of the cause for inaction had been her apparent concern, and reliability in asking for diagnosis and treatment for Child W. In fact when pieced together she was shown to: • Give different information to NHS staff; • Delay taking Child W when recommended for advice from the General Practitioner or specialist staff; • Suggest that Child W ‘marked easily’; • Insist that Child W was never left with other adults; and • Not continue treatments prescribed for herself.   4.2 This was important context for NHS staff to use in making judgements about possible injuries. However risk to Child W increased because: • an unexplained bruise at 12 weeks, and a second within a few weeks were not investigated  • there was insufficient information recorded on the care and living arrangements of Child W and the family; • NHS agencies did not communicate sufficiently with each other, (GP to HV, HV to GP, GP to hospital, hospital to hospital and written information gave no context to brief medical information);  • NHS staff did not consider the range of possible explanations for bruises and fractures seen in a non-mobile baby; and • Child W’s mother presented to different points of contact.  4.3 The NHS Commissioning Overview Report identified six opportunities to consider Child W’s care in the context of safeguarding. Each one of these was missed.  4.4 Crucially the multi-agency strategy meetings held immediately after a Consultant raised concerns (when Child W was six months) did not meet the expectations of Working Together (2010): • The first one was adjourned as there was no representative of the paediatric team; • The CSC Chair was not sufficiently experienced or of the correct grade; • The notes were not available to the next day’s Chair; Page 5 of 8 • The GP was not invited or asked to provide any information; • The hospital based child protection nurse had not read any of the paperwork; • The meeting did not consider the historical information that would have been available on the family; • The meeting did not discuss each presenting injury or symptom; • The mother’s presentation and concern inappropriately influenced decision making; • The participants did not challenge the consultant’s view of ‘probability’; and • Each participant made their own notes and there were no agreed formal records of the meetings.  4.5 The panel agreed at the end of the review that some injuries of Child W were preventable. With hindsight it could be concluded that the injuries were predictable, but there is no evidence that the serious assault could have been predicted.   5. Lessons to be Learnt  5.1 The panel agreed six key lessons to be learned. They are: • Agencies did not take appropriate responsibility for safeguarding. The lack of communication was based on an assumption that someone else would do something if there was a concern; • Representatives of all agencies attending strategy meetings need to fully understand that young babies cannot be injured accidentally and how injuries can be presented; • Staff in all agencies should ensure accuracy and updated detail of living arrangements with more detailed questioning when risk is identified;   • That Manchester Safeguarding Children Board should have in place multi-agency citywide agreement and guidance on how strategy meetings are managed and recorded with monitoring to ensure compliance;  • There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies; and • Consideration is needed on how to identify and flag significant risk from those without formal convictions.  5.2 Panel members were aware that similar recommendations had been made in recent serious case reviews. Manchester Safeguarding Children Board had commissioned an independent person to review the content and process of all serious case reviews since 2007. These reports demonstrated that similar themes were present in previous reviews for each ‘lesson’. In some instances the recommendations were very recent and work to implement them is continuing.  5.3 Following discussion, the panel decided not to make any further repetitive recommendations but to challenge the Board to continue the work on previous ones with monitoring and further reports to MSCB. This should to ensure the full engagement of MSCB members to confirm that all agencies across the city have fully implemented the changes. The questions raised by the challenges are set out in the section below. The action plan prepared by MSCB gives the multi-agency responses to the challenges. Page 6 of 8 Single-Agency Recommendations  Children’s Social Care  1. To issue a briefing to all staff who may be involved in Strategy Discussion meetings to ensure that  those meetings are sufficiently broad in critical analysis of the available information.  2. To ensure continuity of information and knowledge of involved personnel, attendees will sign document and agreed actions. The strategy discussion document will be photocopied and distributed at the meeting. This process will ensure clear and concise information is available to any change of personnel regarding decisions and actions from previous meetings.   3. The Strategy Discussion template, on completion, should be uploaded onto the electronic recording system i.e. MiCare within maximum of five working days. However any critical case where information would be required by managers should be uploaded immediately.   Greater Manchester Police  1. GMP Public Protection Division review the current methods by which PPIU officers are recording the discussion, actions and outcomes at strategy meetings and formulate a standard method which should then be disseminated to all PPIU staff for adoption across GMP.   Central Manchester University Hospitals Foundation Trust  1. a) That the organisation reviews current information sharing processes to ensure there is clarity, consistency and appropriate staffing to manage them;          b) That within this, the organisation reviews and advises on the use of date stamps and the analysis of information received into community health teams.  2. Review of the Hot Week Consultant workload and work practices in order to ensure safe delivery of child protection investigations (though equally applicable to other areas of general paediatrics).  3. Teaching session to consultant general paediatricians and Safeguarding nurses on patterns of abusive soft tissue and bony injuries.  4. Review individual consultant training needs in respect of child protection.  5. Review of format and scheduling of Peer Review Sessions.  Page 7 of 8 6. Introduce standardised record keeping for Strategy Meetings (NB. this has been accepted as a multi-agency recommendation by MSCB).  7. Review and expand Safeguarding Nursing role to maximise their contribution to Section 47 investigations by ensuring that the Safeguarding Nurses contribute  specific expertise as partners in case management. Core standards should be set out so as to achieve a structured approach to case management. These should  incorporate:                 1. Assessment of the facts of the case from all relevant sources.                 2. Analysis of the information and identification of key considerations.                3. Development of a structured plan, which will be incorporated into the overall   plan of management made by the lead consultant. The consultant retains professional responsibility for the case.                4. Evaluation of the outcomes of the agreed plan in conjunction with the responsible consultant.  The evaluation process should include ensuring that any written medical/professional reports have been received, read and acted on appropriately; that minutes of strategy meetings and case conferences are received, digested and acted upon as indicated.    These standards should be embedded as practice and audited for efficacy.  8. Ensure consultants are clear about the role of the Safeguarding Nursing team. The lead consultant for a case should take responsibility for sharing decisions and outcomes with the Safeguarding Nursing team.  9. The current work to identify on site accommodation for the Safeguarding Nursing team should be prioritised by the organisation.  NHS Manchester – GP  1. Recognising the signs of possible physical abuse: All GPs employed by OOH should receive CP (child protection) training to Level 3. This should include recognising abuse in a non mobile child and know what action to take if they have concerns about abuse.  2. Recognising the signs of possible physical abuse: In GP practices all GPs and nurse practitioners who assess children should receive CP (child protection) training to Level 3. This should include recognising abuse in a non mobile child and know what action to take if they have concerns about abuse.  3. The importance of GPs communicating with the Health Visitor and Midwife: GP practices to improve communication with health visitors and midwifes by setting up a regular forum to discuss families of concern.  4. The importance of OOH service communicating with GPs: The OOH service to review the quality of information sent to GPs so that the action to be taken by GPs is clearly stated  Page 8 of 8 Pennine Acute Hospitals Trust  1. PAHT safeguarding team will plan and design a half day training event focusing on this case and in particular on ‘what good looks like’ in child protection report writing, holistic assessment and history taking, challenging explanations for injuries and understanding the child’s perspective.  2. The Pennine Acute Safeguarding Children Group will determine a strategic approach to raising awareness and evaluating practice regarding the need to establish whether or not patients (including adults and young people) have any caring responsibilities at home as part of routine assessment.  Manchester NHS Commissioning Overview Report Recommendations  1. NHS Manchester commissioners of health visiting services to ensure that the current review considers the findings in this case around corporate caseload management and communication with GPs.  2. Primary care commissioners to ensure safeguarding training to GPs and provider training programmes are strengthened further to ensure that: • the plausibility of parents is embedded in training programmes;  • The Core Info: “Bruising in Children” and “Fractures in Children,” focusing on learning around the specific vulnerabilities of babies, is embedded into training programmes.   Multi-Agency Challenges  1. How will MSCB ensure that each agency has robust procedures that are effectively used to protect children?  2. How will MSCB make sure that the use of training and briefing sessions is integrated into practice and seek evidence of the openness to challenge within child protection meetings?  3. How will MSCB satisfy itself that all agencies have systems for routine enquiry that can be used as an evidence base when risk or vulnerability is identified?  4. How will MSCB ensure the management of strategy meetings is continuously compliant with revised and agreed multi-agency procedures?  5. How will MSCB satisfy itself that there are robust and timely communication systems between community services, GP practices, out of hours services and acute services?   6. What action could MSCB take to raise the matter of notifying concern about adults arrested but not prosecuted for assault or wounding a child for wider discussion or action?  