G:\CPT\SAFEGUARDING BOARD\SCR Panels\2014 Reviews\Child M\SCR Report

debbiecra

BMBC

SERIOUS CASE REVIEW RELATING TO CHILD M

OVERVIEW REPORT BY CLARE HYDE M.B.E INDEPENDENT REVIEWER

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CONTENTS .................................................................................................................................................

1. INTRODUCTION AND CONTEXT........................................................................................................... 2

2. METHODOLOGY .............................................................................................................................. 3

3. THE SCR LEARNING EVENT PARTICIPANTS ...................................................................................... 4

4. CHILD M’S FAMILY ...................................................................................................................... 5

5. THE INTEGRATED CHRONOLOGY ............................................................................................... 6

6. ANALYSIS AND RECOMMENDATIONS .......................................................................................... 8

7. AREAS OF GOOD PRACTICE ............................................................................................................... 17

8. SUMMARY OF KEY LESSONS AND RECOMMENDATIONS ............................................................. 17

9. ACTIONS AND DEVELOPMENTS WHICH HAVE HAPPENED SINCE THIS SERIOUS CASE REVIEW PROCESS COMMENCED: ....................................................................................................................... 19

GLOSSARY OF ACRONYMS ................................................................................................................... 22

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1. INTRODUCTION AND CONTEXT

1.1 A Child Protection Medical Examination and a Section 47 investigation commenced on 22nd

April 2014 in respect of Child M, who was then aged 14 weeks, following incidents of

unexplained bruising and weight loss.

1.2 A full skeletal survey of Child M was undertaken on 23 April 2014 at Barnsley Hospital which

identified a suggestion of healed or healing rib fractures along the angles of the left 4th to

7th ribs and an x-ray of the legs raised a concern regarding the possibility of a small corner

fracture. A review carried out by a Paediatric Radiologist at Sheffield Children's Hospital

reported on 28 April 2014 that there were healing rib fractures of the left 4th, 5th and 6th

laterally approximately 4-6 weeks of age. In addition there were metaphyseal fractures of

left distal femur, left distal fibula, right distal femur and right proximal tibia in the region of

2-4 weeks old.

1.3 Child M was the only child of MM (mother) and FM (father). Both parents had current and

historical difficulties which meant that it was likely that they would need support when they

became parents.

1.4 At the time of the Section 47 investigation and the Child Protection Medical Examination

Child M lived with his mother (MM) who had separated from FM in April 2014.

1.5 The Serious Case Review (SCR) was commissioned by the Barnsley Safeguarding Children

Board (BSCB) in line with its statutory reviewing functions as defined in ‘Working Together to

Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare

of children’ (2013).

1.6 Child M was referred to the BSCB SCR Panel on the 9th June 2014

1.7 It was agreed that the period of time covered by the SCR would be from the date that MM’s

pregnancy with Child M was known to agencies which was 1st May 2013 up to 9th June 2014

which was the date that Section 20 of the Children Act 1980 was used to accommodate Child

M in foster care.

1.8 The government has indicated that it supports changes recommended by Professor Eileen

Munro that serious case reviews should be conducted using systems based learning

methodology and it was agreed that important learning could be gained by conducting a

whole system review of Child M in order to conceptualise how services routinely operate

and to identify what is working well or where there are problematic areas.

1.9 The BSCB Serious Case Review Sub Group recognised that the review would need to be as

robust and transparent as the former SCR process and should be measured by the extent to

which it would make a difference and improve Barnsley’s multiagency safeguarding

response.

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1.10 Consequently, the BSCB Serious Case Review Sub Group made a recommendation that the

BSCB should conduct a serious case review to address how agencies had worked together;

identify any additional learning and aggregate lessons from individual organisations and

ensure that an improvement action plan was put in place.

2. METHODOLOGY

2.1 The Serious Case Review was designed and led by Clare Hyde, independent reviewer, from

The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde

developed a review model that would enable participants to consider the events and

circumstances occurring over a period of time during which Child M was injured.

2.2 The analysis in this report uses some elements of the framework developed by SCIE to

present key learning within the context of local systems. This also takes account of recent

work that suggests that an approach of developing over prescriptive and SMART

recommendations have limited impact and value in complex work such as safeguarding

children. For example, a 2011 study of recommendations arising from serious case reviews

2009-2010, (Brandon, M et al), calls for a limiting of ‘self-perpetuating and proliferation’ of

recommendations. Current thinking about how the learning from serious case reviews can

be most effectively achieved is encouraging a lighter touch on making recommendations for

implementation through over complex action plans.

2.3 A serious case review panel was convened of senior and specialist agency representatives to

oversee the conduct and outcomes of the review.

2.4 The panel agreed specific terms of reference that provided the key lines of enquiry for the

SCR in addition to the terms of reference described in national guidance. The key lines of

enquiry included:

How well practitioners understand the potential child protection implications of bruising to a non-ambulant baby?

How confident are professionals around how to act upon bruises to non-ambulant infants and how to escalate concerns?

How well do practitioners recognise and understand complexity within families and what does this mean for practice and supervision?

How well did agencies communicate?

2.5 The panel established the identity of services in contact with the family during the time

frame agreed for the review.

2.6 The SCR aimed to provide an innovative ‘whole system’ approach involving key front line

practitioners (and their line managers) who worked with Child M and adults of Child M’s

family in a learning event. In this way, Child M’s ‘story’ was to be central to the Learning

event. In preparation for the learning event practitioners were asked to complete a

chronology identifying key practice episodes and describing:

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What could / should have been done differently?

What worked well and how was this evidenced?

2.7 It was anticipated that further questions would emerge during the course of the learning

event.

2.8 The learning event took place over a full day. During the first part of the day practitioners

and their line managers had the opportunity to review the combined key practice event

chronologies of each agency; which was represented as a ‘whole system’ timeline. Each

agency then talked through their involvement with Child M and his family. Questions were

asked and comments and reflections made by other participants. The results of this

chronology based exercise informed the second part of the learning event which focused on

identifying areas for improvement (at practitioner, managerial and service levels) and best

practice for agencies working together to safeguard children.

3. THE SCR LEARNING EVENT PARTICIPANTS

3.1 The following agencies have provided chronologies and participated in the Learning event:-

Barnsley Hospital NHS Foundation Trust (BHNFT)

Named Midwife Safeguarding Children

Community Midwife

Registrar

Named Doctor Safeguarding Children/Consultant Paediatrician

South West Yorkshire Partnership Foundation Trust (SWYPFT)

Business Manager Children’s Services

Named Nurse Safeguarding Children

Nurse Advisor Safeguarding Children

Clinical Lead 0-19 Pathway

Health Visitor

NHS Barnsley Clinical Commissioning Group

Named Doctor Safeguarding Children

Designated Nurse Safeguarding Children

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GP

Service Manager, Children’s Social Care

Assistant Director of Nursing & Patient Experience, NHS England

3.2 Also in attendance at the Learning Event were:-

Admin Support Worker, BSCB

Business Manager, BSCB

3.3 Child M’s family were invited to contribute to the SCR but felt unable or declined to do so.

4. CHILD M’S FAMILY

How did agencies respond to Child M and his Family?

4.1 Child M and his family raise a number of practice issues, both for individual agencies and for

the BSCB; particularly in relation to families with complex and/or multiple needs and risk

factors. These issues are detailed in section 6 of this report.

4.2 MM was aged 39 when she became pregnant with Child M and FM was aged 22. MM and

FM had been in a relationship for approximately 3 years at the time of Child M’s conception.

FM left MM when Child M was approximately 12 weeks old and began a new relationship.

4.3 Although the time frame of the review covers the period 1st May 2013 up to 9th June 2014;

agencies held relevant information about MM, FM and FM’s family which pre-dated this

period.

MM was reported to have been exposed to domestic abuse as a child and to

physical abuse from her stepfather.

MM was being treated for depression and low mood in 2009 and had taken a drug

overdose in 2000 following a relationship break down.

MM had a referral for fertility investigations in March 2012 and in December 2012

was treated for an ectopic pregnancy following which she felt she was not coping

and also felt unsupported by her partner (FM).

FM’s GP records from 1996 indicate that he had autism and a behaviour disorder

however there was no evidence that FM had ever been formally assessed and

diagnosed as having autism or a behaviour disorder.

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In 2009 FM was referred to the Community Mental Health Team (CMHT) due to

increasing outbursts of temper and anger. A history of childhood exposure to

parental substance misuse, mental illness and domestic abuse was recorded.

5. THE INTEGRATED CHRONOLOGY

5.1 The review attempted to identify how agencies and organisations responded to the needs of

Child M and his family between 1st May 2013 and 9th June 2014

5.2 Participating agencies carried out reviews of their records and materials including:

Electronic records

Paper records and files

Patient or family held records

5.3 From the key practice episodes it is possible to build a picture of the stress and strain that

MM and FM were experiencing and the corresponding increase in indicators of risk to Child

M. This picture is summarised below.

MM

5.4 There is no doubt that MM experienced several significant events which would have

negatively impacted upon her mental wellbeing prior to and during her pregnancy with Child

M. Additionally MM had periodically experienced poor mental health and was taking anti-

depressant medication for some time prior to becoming pregnant with Child M.

5.5 These significant events (there may be others that are not known to local agencies) are

described below in chronological order.MM was referred for fertility investigations in March

2012 and in December 2012 suffered an ectopic pregnancy.

5.6 On 4th February 2013 MM sought treatment from her GP and was described as ‘tearful’

feeling that her partner was not supportive about the ectopic pregnancy.

5.7 By 22nd May 2013 MM’s pregnancy with Child M was confirmed by the GP.

5.8 Throughout the period of her pregnancy MM reported various stressors and the impact that

they were having upon her mental health. These were recorded by the GP and MW but not

shared with the HV service despite the phone calls from the HV service to the GP. Nor did

the MW share any historic information when she contacted the HV to ‘hand over’ the care of

MM.

5.9 These stressors included:

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Insomnia caused by severe itching

Thoughts of self- harm

Feeling angry and losing her temper with her partner

Distressed and itching

5.10 On 22nd October 2013 MM was suspended from her healthcare role following allegations by

co-workers that she had verbally abused a patient. Being suspended from work under such

circumstances would have caused significant stress to MM. A 2004 report for Brian Jenkins

MP, member of the Public Accounts Committee ‘Suspension Failure in the NHS’ describes

the impact of suspension on nursing and midwifery staff;

‘Suspension leaves the person in a state of shock. People have contacted me, expressing

their devastation, disbelief, hurt, isolation, anger, mental ill-health, even suicidal

thoughts, to name some of the emotions felt’.

5.11 There were two further recordings by the GP that MM was experiencing stress before the

birth of Child M one of these was directly attributed to her suspension from her job.

5.12 Child M was delivered by caesarean section on 15th January 2014; and on the same day; the

midwives recorded that MM was distressed because ‘all family members wanted to visit’.

5.13 On day 7 and day 16 post-delivery MM reported to her midwife (M1) that she was tearful

and was upset and crying. MM told the M1 that she had not thoughts of harming the baby

but that she could understand how people could shake their babies. It is important to note

that the issue of shaking a baby is routinely raised by midwives and this was the case with

MM. It does not appear that M1 explored what support was available to MM or that she

considered instigating an ‘early help’ assessment.

5.14 MM and Child M were seen by 3 different midwives within a period of 5 days following her

discharge from hospital.

5.15 Between 31st January 2014 and 3rd February there was a discussion between (M1) and the

student Health Visitor (HV1) as the midwifery service ‘handover’ to the health visiting

service and M1 expressed her concerns about MM’s mental wellbeing.

5.16 On 3rd February 2014 MM was prescribed anti-depressants and pain killers by her GP. The

pain killers were in respect of post-operative pain from the caesarean section.

5.17 Circa 5th February 2014; according to a Statement provided by MM to the Police, Child M

was 3 weeks old when she returned to work (working for an agency 2 long shifts per week).

MM did not tell any health professional involved in her care or in the care of Child M that

she was returning to work so soon after the birth of her baby by caesarean section.

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5.18 On 4th March 2014 MM mentioned bruises (which were not visible) to HV1. MM told HV1

that she had told her GP about the bruises. This is the first time that Child M was noted to

have lost weight.

5.19 On 13th March 2014 that MM mentioned to her GP that Child M had bruises and the GP

noted a very faint bruise to Child M’s right knee. MM mentioned bruising again on 14th

March 2014 to HV1 and two faint bruises to Child M’s knees were noted.

5.20 On 11th April 2014; MM again mentioned the bruising at a visit to the baby clinic. She also

disclosed that she and her partner had separated and that he was in a new relationship. This

is a further significant negative life event which will have had an impact on MM’s mental

wellbeing.

5.21 MM admitted to assaulting FM during their relationship. This admission was made to the

police after the injuries to Child M had been discovered.

FM

5.22 FM was exposed to significant domestic abuse as a child along with allegations (against his

father; Child M’s grandfather) of assault, physical chastisement and sexual abuse in relation

to FM’s younger sibling.

5.23 FM was also living with a parent who had mental health issues.

5.24 In 2009 at the age of 17, FM sought help with managing his temper and anger.

5.25 Between September 2012 and January 2014 (aged 20 to 23) FM:

Underwent primary fertility investigations

Supported or tried to support his partner following an ectopic pregnancy

Became a first time father (the birth of Child M)

Went through the breakdown of his relationship with MM

6. ANALYSIS AND RECOMMENDATIONS

6.1 This section sets out an analysis of key findings and associated recommendations that are

designed to offer challenge and reflection for the BSCB and partners.

6.2 The key lines of enquiry for the SCR were explored through the process of the Learning

Event and considered together with the details submitted in individual agency chronologies:

How well do practitioners recognise and understand complexity and risk and what does

this mean for practice and supervision?

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6.3 Individual risk factors are explored in more detail later in this section, however, it is

important not to lose sight of the whole picture and to consider the opportunities available

to practitioners to recognise the accumulating concerns over a relatively short period of

time and assess the potential risk to the child. There were a number of factors present in

this case which are known to be associated with risk to children, yet these were not

adequately assessed as a whole.

6.4 Child M was born into a relationship dynamic which had inherent risk factors and to two

individual parents who had current and historical difficulties which were indicators of risk to

Child M.

6.5 However; as individuals and as a couple; MM and FM presented as ‘normal and respectable’

and each was employed in a responsible health or caring role. They were credible, respectful

and respected in their contacts with practitioners and the GP’s, midwives and health visitors

were supportive towards MM in particular as her physical and mental wellbeing fluctuated.

6.6 That MM was, in the main, the focus of professional concern had serious implications for

Child M and meant that safeguarding concerns were delayed or absent. One example of this

was the telephone call made by HV3 to the Safeguarding Nurse Advisor on 17th April 2014. A

referral to Children’s Social Care was discussed but it was felt that this would add to MM’s

anxieties and HV3 was unable to speak to MM in person with regards to this. Following a

discussion with HV2 (Team Leader) it was agreed that HV3 would carry out a home visit on

22/04/14. This delayed a referral to both the CAU and Children’s Social Care by 5 days during

which time Child M could have sustained other injuries.

6.7 Other than his own GP; practitioners did not know about FM’s difficult and undoubtedly

traumatic childhood exposure to domestic violence, parental mental illness and substance

misuse. Routine screening for childhood traumas which may compromise an expectant

father’s parenting is not carried out and would be difficult to justify across a total

population.

6.8 All of these factors meant that complexity of risk and need was not well recognised or

understood and there was a failure to recognise MM and FM’s lack of resilience and ability

to cope as individuals and as a couple.

6.9 Fortunately Child M did not die however his injuries were serious and numerous and had

occurred in the first 4 months of his life. His most recent injuries at the time of his medical

examination were estimated to be between 2 and 4 weeks old.

6.10 Learning from other serious case reviews where children have died or been seriously injured

provides a useful reference for identifying and responding to risks. For example; analysis of

183 child homicides in 83 different local authority areas was carried out in 2009 by Ferguson

and Osborne. This analysis revealed that:

Children under the age of one are the most vulnerable – one third of all cases

(34%). The analysis also revealed that babies are significantly more likely to be killed

in the first three months of their lives – 51% of the sample of under ones.

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Around one in three child homicides involved a parent or carer (most often the mother’s new boyfriend) who was aged 22 or under.

Domestic violence was a background factor in 41% of the cases

43 children were killed very shortly after their parents separating, or announcing

plans/wishes to separate.

In the majority of such cases, there had been a prior history of domestic violence;

69% of cases.

In a few cases, separation was the trigger for parents with a pre-existing mental

illness like depression – mostly female – to kill their children.

Depression was a pre-existing diagnosed mental health problem in 19 – 50% of cases

where a mentally ill parent or carer killed a child. The majority (63%) of these killers

were women.

In 32% of all cases the killer was described in the press, quoting people who knew

them well; or by coroners at inquests - as ‘devoted’ parents.

6.11 Child M’s family shared many of these characteristics and risk factors; however it did not

appear that any practitioner carried out a comprehensive risk assessment of the ‘whole

family’ (including his paternal grandparents who were involved in his care).

6.12 Complexity of risk and need is not always obvious within a family. MM and FM each had

individual needs which may well have been compounded by them coming together as a

couple.

6.13 Some practitioners who participated in the Learning event described MM and FM as

‘leading’, ‘controlling’ ‘manipulative’ and ‘strange’. (One example of this is MM’s statement

on 4th March 2014 to HV1 that she had seen her GP about bruising to Child M and that a

blood disorder was being considered. The GP’s records however indicate that this

consultation with MM did not take place until 14th March 2014). These attributes were seen,

in some instances, through a retrospective lens, and it is vital that practice and supervision

enable practitioners to ‘stand back’ and reflect on families who may not present as complex

or high risk.

6.14 Because complexity in this case was not fully recognised or understood; contributed to in

part by the fact that some agencies did not share information about stress factors for MM;

the family and it’s individual members were not offered targeted ‘early’ help or assessed

using the comprehensive assessment framework.

6.15 There were some instances of poor communication in this case which also contributed to

complexity and risk not being recognised and the appropriate ‘early help’ offer and/ or a

comprehensive risk assessment being undertaken.

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Recommendations:

• Adopting a reflective approach to case management, supervision and ongoing

professional development which incorporates an understanding of complex and

compounding risk offers opportunities for agencies and practitioners to improve

their responses to families and crucially, to enhance the safety and protection of

children. Such approaches should offer opportunities for individual professionals

and multi- agency groups of professionals to reconsider their work in this area; this

should take into account how they understand complexity and their response to it.

• In particular, relevant BSCB partners should consider developing supports for

student and newly qualified Health Visitors, social workers and midwives ensuring

that they have access to extended/enhanced supervision and group support to

discuss themes and concerns. (Note: Newly qualified Social Workers have an

assessed year in practice post qualification that includes regular supervision not only

from their Team manager but also sessions with the Programme Manager which

support professional development via reflective practice).

• The BSCB should be assured that relevant partners should consider developing

guidance for ‘cause for concern triggers’ from Midwifery to Health Visiting to ensure

that triggers are commonly understood and standard responses are described.

• Relevant BSCB partners should ensure that practitioners are aware of the

importance of offering help and support as early as possible in a child’s life and that

they have a sound working knowledge of local services and supports available to

families.

How well practitioners understand the potential child protection implications of bruising to a

pre-mobile baby?

6.16 MM reported bruising on at least 4 separate occasions to two GPs, to a Student Health

Visitor (HV1) and to HV2 and HV3

Child M’s Contact with GP’s

6.17 Two GPs; GP1 and GP3; observed the bruising although the bruises were difficult to see as

they had faded and MM had to point them out.

6.18 On 13th March 2014 MM saw GP3 for her own and Child M’s antenatal check. A discussion

about blood disorders took place with MM as a possible cause Child M’s bruising. GP3

advised MM to take Child M for blood tests via an outpatient’s clinic and the relevant form

was given to MM with instructions to attend outpatients as soon as possible. This was not

actioned by MM and the GP did not check that MM had arranged for blood tests to be

carried out until 18th March 2014.

6.19 On 22nd April 14 MM attended the GP’ surgery with Child M and was seen by GP1. This

urgent referral to GP1 had been from HV2 as there were concerns about the bruising and

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about Child M's weight which; by this time was increasing slightly. Child M was not weighed

by GP1. MM mentioned a bruise to Child M's chin which was said to have been difficult to

see. GP1 had been concerned that mum had not taken Child M for blood tests and planned

to call the Consultant on Call after surgery, however events overtook and the Named

Midwife for Safeguarding contacted the GP and was advised that the child had been taken to

the CAU at the Hospital.

6.20 Neither GP considered, expressed or recorded safeguarding concerns. Neither GP consulted

with any other professional to discuss the bruising to Child M or referred to relevant BSCB

guidance on bruising to pre-mobile babies.

6.21 There was a lack of urgency from the GP’s in relation to ascertaining the cause of bruising.

Child M’s Contact with the Health Visiting Service

6.22 On 4th March 2014; MM mentioned to HV1 that Child M had had 2 little bruises on his face

and that this had also been mentioned to her GP who reportedly said Child M may have thin

blood but the test for this can be quite traumatic and would probably rectify itself. HV1

documents that there was no visible bruising at that contact. HV1 did not document that she

considered or expressed safeguarding concerns or that she referred to relevant local section

47 protocol.

6.23 MM also mentioned bruising to HV2 at a baby clinic appointment on 11th April 2014. MM

also told HV2 that she had not taken Child M for blood tests as advised by her GP due to

family circumstances. Although HV2 did not see bruises to Child M she made arrangements

for MM to visit her GP the same day.

6.24 Child M’s weight had begun to increase slightly at this clinic appointment. HV2 also made an

appointment to visit Child M at home the following week as she felt uneasy about MM’s

presentation throughout her attendance at the baby clinic. This home visit appointment was

later cancelled by MM.

6.25 On 17th April 2014 HV3 reviewed Child M’s notes. HV2 advised HV3 to contact the GP for the

outcome of MM’s visit to the GP on 16th April 2014.

6.26 During 17th April 2014 HV3 telephoned MM to discuss the outcome of her visit to the GP.

MM reported that the GP was not unduly concerned about Child M’s weight loss. GP

reportedly told MM that as Child M had not lost any weight; to carry on but wanted to

review him in a month.

6.27 HV3 also clarified with GP1 what advice had been given in relation to the bruising. GP1

confirmed that blood tests were being considered but GP1 was not concerned. HV3

repeated herself to GP1 but as GP1 had not observed any bruising he was not concerned.

GP1 advised HV3 to refer back to him if any further bruising noted. GP1 did acknowledge a

drop in Child M’s weight.

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6.28 HV3 also telephoned the Safeguarding Nurse Advisor and discussed a referral to Children’s

Social Care but after discussion the Safeguarding Nurse Advisor felt this would add to MM’s

anxieties as HV3 was unable to speak to MM in person with regards to this. This decision

was in the context of Child M gaining weight, the GP’s lack of concern and Child M appearing

to be a happy and well baby.

6.29 Also on 17th April 2014; HV3 discussed the case with HV2 (Team Leader) and agreed that a

home visit would be carried out on 22nd April 2014. This delay of 5 days is excessive given

the level of concerns which were being identified.

6.30 On 22nd April 2014 between 10.00am and 17.40pm the actions described below were taken:

6.31 HV3 contacted the Child Assessment Unit (CAU) at Barnsley Hospital NHS Foundation Trust

to request advice. Summarising that Child M; a 17 week old baby had a history of bruising at

6-8 weeks and at 13 weeks. HV3 was advised to check Child M and refer to Children’s Social

Care if any safeguarding concerns and to send to CAU for assessment. It was jointly planned

between HV3 and the Paediatric Registrar that if the GP did not follow those actions once

Child M had been seen then HV3 would herself take the required actions.

6.32 The Paediatric Registrar at the CAU received the first telephone call from HV3 regarding Child M who then discussed the information she had been given with the Paediatric Consultant. The Consultant shared her view that there were significant causes for concern.

6.33 In parallel time lines, both HV3 and the Paediatric Registrar were trying to get the child assessed appropriately at the CAU although there may have been some lack of appreciation or understanding on each side that this was the case.

6.34 HV3 carried out the planned home visit and asked to be shown any bruising, she also asked

for Child M to be undressed and physically examined him. HV3 weighed Child M and he had

gained a small amount of weight. HV3 acknowledged her safeguarding concerns with MM

and FM. This was good practice on the part of HV3.

6.35 HV3 contacted the GP surgery and gave Child M’s history and was asked to call back to speak

to GP1.

6.36 HV3 telephoned the Paediatric Registrar as requested and described Child M’s weight loss

and bruising. HV3 was informed that Child M had been discussed with a Paediatric

Consultant who also had concerns with regards to presenting information. A plan was

agreed to await outcome of HV3’s call to Child M’s GP and refer to the CAU if the GP did not

do so. HV3 agreed to liaise with the Paediatric Registrar following the appointment.

6.37 HV3 telephoned GP1 who was not immediately concerned. HV3 reiterated her safeguarding

concerns but reported that the GP had no immediate concerns.

6.38 HV3 telephoned the Paediatric Registrar and informed her of the GP’s assessment and

outcome. The Paediatric Registrar expressed concerns in the delay in seeing Child M at the

CAU. HV3 informed the Registrar that she would follow local safeguarding policy and refer

to Children’s Social Care following their telephone call.

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6.39 HV3 telephoned the Duty Social Worker; Children’s Social Care who expressed concerns

about the delay in reporting bruising and lack of follow up or further investigation.

6.40 HV3 telephoned MM to inform her of the referral to Social Care and safeguarding concerns.

6.41 HV3 had a telephone conversation with the Named Midwife Safeguarding Children BHNFT

and the Named Midwife requested information about action to be taken by Children’s Social

Care. The Named Midwife expressed concerns that Child M had not attended the CAU and

she also contacted the GP surgery to express her concerns. She stated that GP had said that

if she had been aware of the full history of bruising at 6 and 8 weeks she would have

referred Child M to CAU. The Named Midwife requested more clarity re Social Care plan

from HV3. HV3 was unable to do this due to time of day so the Named Midwife agreed to

do this herself.

6.42 The GP’s and HV1 involved in the care of Child M did not demonstrate that they fully

understood the potential child protection implications of bruising to a pre-ambulant baby. In

the case of the GP’s there was a lack of urgency arising from this lack of understanding

which made HV3’s attempt to escalate her concerns difficult despite which she persisted in

her efforts.

None of the GP’s or the health visitors referred to the relevant local policy for bruising to

pre-ambulant babies. The factors which influenced their practice and led to delayed or

absent safeguarding concerns for Child M included:

MM appeared to be a ‘normal, respectable mum’.

MM her-self brought the bruises to their attention and accompanied this with a

plausible account of having sought advice from her GP and the possibility of an

underlying blood disorder.

The bruises were barely visible and would not have been noticed if MM had not

brought them to the practitioners’ attention.

MM appeared to have formed a loving bond with Child M and although his weight

loss was a concern, he appeared to be a happy, engaged and engaging baby.

MM and FM were both employed in health /caring roles and were plausible in their

dealings with practitioners.

MM and FM were described as being ‘leading’, ‘controlling’ or ‘manipulative’ in their

contacts with practitioners. E.g. MM told HV1 that she had asked her GP’s advice

about bruising to Child M on 4th March 2014 when in fact she had not done so.

6.43 Recommendations:

BSCB should urgently ensure that all practitioners are familiar with the local section 47

protocol for responding to concerns about injuries or abuse in infants under 1 year. The

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protocol and any training or awareness raising activities with practitioners should stress that

no matter what rationale/reassurance is provided by parents or carers; any bruising on a

non-ambulant baby should be treated as a non- accidental injury until proven otherwise.

Even if the bruising is not seen by a practitioner and parents or carers report bruises this

should be treated as a significant concern requiring immediate investigation and escalation.

BSCB partners should raise practitioner’s awareness of the protocol Resolving Professional

Disagreement Protocol where there is lack of consensus about or professional agreement

about escalating safeguarding concerns. The protocol should take into account the balance

of power / hierarchy which may exist between professionals and balance this with an

absolute directive i.e. ‘if in doubt; escalate’.

Some action has already been taken by the Designated Nurse Safeguarding Children, NHS Barnsley CCG and NSPCC leaflets on bruising have been delivered to all GP practices highlighting the issue of bruising to non-ambulant babies. However; it is recognised that further work needs to take place with GP’s in respect of suspected non-accidental injuries to a child and the it was agreed that a multi-agency group comprising of the Designated Nurse Safeguarding Children, Designated Doctor Safeguarding Children, Consultant Paediatrician, GP and Registrar would meet to develop a flowchart for all agencies (with input from BHNFT) in order to minimise any ambiguity.

How confident are professionals around how to act upon bruises to non-mobile infants and

how to escalate concerns?

HV2 and HV3 had safeguarding concerns about Child M. Between 17th April and 22nd April

2014 HV3 discussed the case with HV2 (Team Leader) and shared her concerns. HV3

reported that she faced difficulties in her attempts to escalate her safeguarding concerns via

Child M’s GP. This was because GP1 did not share her safeguarding concerns. HV3 spent

many hours attempting to escalate her concerns and there was lack of clarity about how she

should do this. HV3 did not appear to refer to the Resolving Professional Disagreement

Protocol.

There also appeared to be confusion and lack of clarity amongst other practitioners who participated in the Learning event about how and under what circumstances; to refer a child to the CAU.

Recommendations

Urgent action is required to clarify, share and promote the local referral protocol to the CAU; with a specific focus upon cases of bruising to non-mobile children.

Action is required to ensure that the current referral protocol is fit for purpose and that there will is a clear pathway described within it and that there are plans to promote and disseminate it in place. N.B. this work is underway in consultation with partners.

BSCB partners should raise practitioner’s awareness of the Resolving Professional Disagreement Protocol where there is lack of consensus about or professional agreement about escalating safeguarding concerns. The protocol should be reviewed to ensure that it takes into account the balance of power / hierarchy which may exist between professionals and balance this with an absolute directive i.e. ‘if in doubt; escalate’.

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How well did agencies communicate?

• Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2012

identifies that nationally there are problems in how information is sought and shared.

Many serious case reviews identify issues in regard to the importance of securing

relevant historical information in order to inform current assessments.

• In this case gaps in the sharing of information between the Midwifery service and the

Health Visiting service meant that MM did not receive an introductory ante-natal visit

from a Health Visitor. In this case it was identified that the ante natal ‘booking’ system

(SystmOne) failed to communicate MM’s details between the Midwifery and Health

Visiting services. When a woman is booked for pregnancy by a midwife all bookings are

forwarded to the Child Health Department who then notify the Health visitor via the IT

system so that an antenatal visit can be arranged. In this case there was a system failure

as all other woman booked around the same time as Child M’s mother were on the

notification list.

Communication between the GPs, Midwifery and the Health Visiting Service was not

effective and offered no opportunity to discuss the bruising to Child M and his weight

loss and any emerging safeguarding concerns.

GPs did not inform the Health Visiting Service that MM had been prescribed

antidepressants or that she had been suspended from work; both issues were significant

in terms of assessing Child M’s safety.

The GPs and midwifery service did not inform the Health Visiting service about MM’s

insomnia and itching.

This contributed to the fact that targeted early help and a full assessment of the ‘whole

family’ circumstances did not occur.

For some practitioners the use of the integrated timeline at the Learning event was the

first opportunity that they had to ‘see the whole picture’ for Child M and his family.

Some of the participating practitioners were unaware of key pieces of information about

Child M and his family.

• Good information sharing can be characterised by a clear understanding and shared

knowledge about a child within the context of his/ her family, as they progress through

various systems of help and support that they and their families encounter.

6.45 Recommendations:

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Communication between the GP’s, the Midwifery Service and the Health Visiting service

should be reviewed to ensure that:

The Health Visiting Service are aware of any relevant previous medical history and

any emerging concerns.

The referral process from the Midwifery Service to the Health Visiting Service is fit

for purpose.

Communication around causes for concern and case reviews between GPs and

Health Visiting and Midwifery Services should be urgently reviewed and

mechanisms put in place for regular dialogue between all agencies.

Good practice such as ‘Family of Concern’ meetings should be considered to

improve communication, information exchange and to provide opportunities to

discuss more complex families.

Liaison and good information sharing between the component parts of the health

service is critical and this serious case review offers an opportunity to review how

local health partners currently liaise and share information.

7. AREAS OF GOOD PRACTICE

7.1 HV2 and HV3 were concerned for Child M’s safety. HV3, although lacking clarity about some

of the processes for escalating concerns or referring Child M to the CAU; expended all her

efforts (guided and supported by HV2) to ensure that she shared and escalated her concerns

about Child M’s welfare.

7.2 The Named Midwife; Safeguarding Children (BHNFT) and the Paediatric Registrar (CAU) also

both recognised the safeguarding concerns for Child M and were proactive in ensuring that

he was assessed appropriately.

8. SUMMARY OF KEY LESSONS AND RECOMMENDATIONS

8.1 It appears from the review of his x-rays, that Child M first sustained injuries at approximately

6 weeks of age and remained in an extremely unsafe situation, sustaining further serious

injuries, for a further 10 weeks before he was removed from the situation.

8.2. There was one occasion when MM pointed out visible (if difficult to see) bruises and these

were observed by health practitioners. There were therefore, critical opportunities to

protect Child M from further harm which were lost. Other practitioners heard about but did

not see any bruises on Child M, and similarly, it is possible that had staff who heard about

bruising followed the section 47 protocol for responding to concerns about injuries or abuse

in infants under 1 year; Child M would have been referred immediately to the CAU.

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8.3. The Serious Case Review has identified that practitioners who either heard about or saw bruising were not familiar with section 47 protocol for responding to concerns about injuries or abuse in infants under 1 year and neither were they sufficiently sceptical about what could cause bruises in such a young baby. In the case of the student HV; she had no prior experience which would have informed her assessment of risk to Child M and her subsequent decision making. In the case of the GP, awareness and training was not sufficient to raise concerns and trigger a safeguarding response.

8.4. The participants at the Learning Event discussed ‘sceptical challenge’ in some depth in relation to this case. Lack of sceptical challenge can arise from training deficits so the professional may not realise there is actually something to be worried about, but often it is to do with either the dynamic of the relationship of the practitioner with the family or the degree to which organisational culture and ‘daily practice’ supports challenge (e.g. supervision which is challenging provides a model for work with families). Challenge can be perceived as aggressive or confrontational rather than a request for more information. Sometimes practitioners do not challenge as they believe it will damage trust with families.

8.5 The value of taking a sceptical stance in the interests of child safety is perfectly demonstrated in this case and the challenge for BSCB and its partners is to support staff and their line managers to see the appropriateness of challenge as a search for more information.

8.6 Summary of Recommendations

1. Adopting a reflective approach to case management, supervision and ongoing professional development which incorporates an understanding of complex and compounding risk offers opportunities for agencies and practitioners to improve their responses to families and crucially, to enhance the safety and protection of children. Such approaches should offer opportunities for individual professionals and multi- agency groups of professionals to reconsider their work in this area; this should take into account how they understand complexity and their response to it.

2. In particular, relevant BSCB partners should consider developing supports for student and newly qualified Health Visitors, social workers and midwives ensuring that they have access to extended/enhanced supervision and group support to discuss themes and concerns. (Note: Newly qualified Social Workers have an assessed year in practice post qualification that includes regular supervision not only from their Team manager but also sessions with the Practice Educator which support professional development via reflective practice). See also 9.1 below.

3. BSCB should ensure that relevant partners consider developing guidance for ‘cause for concern triggers’ from Midwifery to Health Visiting to ensure that triggers are commonly understood and standard responses are described.

4. Relevant BSCB partners should ensure that practitioners are aware of the importance of offering help and support as early as possible in a child’s life and that they have a sound working knowledge of local services and supports available to families.

5. BSCB should urgently ensure that all practitioners are familiar with the local section 47 protocol for responding to concerns about injuries or abuse in infants under 1 year.

6. The protocol and any training or awareness raising activities with practitioners should stress that no matter what rationale/reassurance is provided by parents or carers; any bruising on a non-ambulant baby should be treated as a non- accidental injury until proven otherwise. Even if the

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bruising is not seen by a practitioner and parents or carers report bruises this should be treated as a significant concern requiring immediate escalation, professional discussion and investigation.

7. Action is required to ensure that the current referral protocol is fit for purpose and that there will is a clear pathway described within it and that there are plans to promote and disseminate it in place. N.B. this work is underway in consultation with partners. See 9.2 below.

8. BSCB partners should raise practitioner’s awareness of the Resolving Professional Disagreement Protocol where there is lack of consensus about or professional agreement about escalating safeguarding concerns. The protocol should take into account the balance of power / hierarchy which may exist between professionals and balance this with an absolute directive i.e. ‘if in doubt; escalate’.

9. Communication between the GP’s, the Midwifery Service and the Health Visiting service should be reviewed to ensure that:

a. The Health Visiting Service are aware of any relevant previous medical history and any emerging concerns.

b. The referral process from the Midwifery Service to the Health Visiting Service is fit for purpose.

c. Communication around causes for concern and case reviews between GPs and Health Visiting and Midwifery Services should be urgently reviewed and mechanisms put in place for regular dialogue between all agencies.

d. Good practice such as ‘Family of Concern’ meetings should be considered to improve communication, information exchange and to provide opportunities to discuss more complex families.

e. Liaison and good information sharing between the component parts of the health service is critical and this serious case review offers an opportunity to review how local health partners currently liaise and share information.

9. ACTIONS AND DEVELOPMENTS WHICH HAVE HAPPENED SINCE THIS SERIOUS CASE REVIEW PROCESS COMMENCED:

9.1 It is recognised nationally that as a result of the ‘Call to Action’ for Health Visiting has resulted in recruiting staff into Health Visiting that previously may not have met the entry criteria. There has now been a national directive that health visitors within the first year of practice will need mentoring. As a direct result of the learning event for this case SWYPFT have identified that there is a need for newly qualified staff to have protected time in receiving monthly supervision. This supervision will be delivered by the safeguarding children team where key themes will be explored in order to help with practice. This will not replace the requirement to have individual provision for child protection supervision as per the supervision policy requirements.

9.2 Some action has already been taken by the Designated Nurse Safeguarding Children, NHS Barnsley CCG and NSPCC leaflets on bruising have been delivered to all GP practices highlighting the issue of bruising to non-ambulant babies. However; it is recognised that further work needs to take place with GP’s in respect of suspected non-accidental injuries to a child and the it was agreed that a multi-agency group comprising of the Designated Nurse Safeguarding Children, Designated Doctor

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Safeguarding Children, Consultant Paediatrician, GP and Registrar would meet to develop a flowchart for all agencies (with input from BHNFT) in order to minimise any ambiguity. This group of practitioners have met and a flowchart has been developed which is being consulted upon at the time of writing this report.

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GLOSSARY OF ACRONYMS

AN Ante natal ANC Ante natal clinic ANDU Ante Natal Day Unit BHNFT Barnsley Hospital NHS Foundation Trust BP Blood pressure CAMHS Child & Adolescent Mental Health Service CAU Child Assessment Unit CMHT Community Mental Health Team CMW Community Midwife CPT Community Practice Teacher CSC Children’s Social Care CTG Cardiotocograph CXR Chest X-Ray DNA Did not attend (an appointment) DV Domestic violence EEG Electroencephalograph F/U Follow up GP General Practitioner HV Health Visitor Imms Immunisations LMP Last menstrual period LSCS Lower Segment Caesarean Section MH Mental health MSU Midstream specimen of urine NAD Nothing abnormal detected / no abnormalities detected OPA Outpatients appointment Paed clinic Paediatric clinic (at Barnsley Hospital) PHQ Patient Health Questionnaire Pt Patient RCN Royal College of Nursing RGN Registered General Nurse SCBU Special Care Baby Unit SPo2 Oxygen saturation SWYPFT South West Yorkshire Partnership Foundation Trust TL Team Leader