29
Serious Case Review Baby Penny (The SSCB has used a pseudonym to protect the identity of the child and family) Publication date 26 November 2015
Serious Case Review
Baby Penny (The SSCB has used a pseudonym to protect the identity of the child and family)
Publication date 26 November 2015
Conten
1. D 2. 3.
4. 5. 6.
7. 8.
9.
10.
11.
AAAA
ts
Decision to
Serious Cas
Scope and
Child’s Voic
Agency inv
Areas of Sig
ASP 1: Ch ASP 2: M en ASP 3: Op ASP 4: Lac
role
ASP 5: Co
Agency lea
Findings
Summary a Recommen Appendices
Appendix 1Appendix 2Appendix 3Appendix 4
o hold a Seri
se Review a
Terms of R
ce and the
volvement w
gnificant Pr
hildren’s Ser
Managerial Ondorsement
pportunitie
ck of full coe of fathers
ontext in wh
rning and i
and Conclus
ndations to
s
The SCR Roles a Method Referen
ious Case R
approach
eference
Family’s Pe
with The Fa
ractice (ASP
rvices’ Resp
Oversight at and sharin
s to suppor
onsideration
hich profess
mproveme
sions
SSCB
R Review Tend Responsdological Limnces
Review (SCR
erspective
amily
P)
ponse to Re
and Supervisng of assess
rt through e
n of history
sionals wer
ent
eam includinsibilities in tmitations
R)
eferrals from
sion ‐ Timelsments
early interv
y and the co
re working
ng Reviewethe SCR Proc
m other Age
liness of com
vention or C
onsideration
r biographycess
encies
mpletion,
CAF missed
n of /
y
2
Page
3
3
5
5
6
9
10
12
13
13
15
16
16
19
20
22 25 26 29
1
1.1
1.2
1.3
2 T
2.1
2.2
2.3
1Regulatreviews olessons to(i) the chwhich the
Decision to
Baby Penny
May 2014.
The Case R
held a scop
the death o
SSCB endo
delay in the
appears tha
a contribut
Several oth
year have o
that this re
previous S
recommen
The approa
It was agr
approach t
a chain of
beyond the
Working To
This review
method fo
supports an
Senior man
with the fa
which met
ion 5 of the Lof serious caso be learned’.hild has died; e Authority, th
o hold a Ser
y was born
The Corone
Review Sub
ping meetin
of Baby Pen
rsed the re
e completio
at the large
tory factor.
her reviews
occurred in
eview shou
SCRs but
dations from
ach we used
eed that t
hat recogni
events an
e control o
ogether 201
w therefore
r better un
nd solutions
nagers from
amily at the
on four occ
Local Safeguases in specifie. A SCR is onor (ii) the chilheir Board pa
ious Case R
n in August
er’s finding
b‐committee
g on 9 June
nny met the
ecommenda
on of this SC
e volume of
relating to
Sunderlan
uld not onl
also shou
m other rec
d
he review
ised that th
d the inter
f the indivi
13.
was under
nderstandin
s can be mo
m key agenc
e time of Ba
casions duri
arding Childreed circumstane where: ‘a) ald has been srtners or othe
Review (SCR
2013 and
was that th
e of Sunde
e 2014 and a
e criteria for
ation at th
CR is an issu
f work in re
the death a
d in recent
ly consider
uld pay s
cent review
be undert
e actions an
raction of
iduals invol
rtaken usin
ng why goo
ore easily id
cies who ha
aby Penny’s
ing the SCR
en Boards (SSnces and to ‘abuse or negleeriously harmer relevant per
R)
died as a re
his was an a
rland Safeg
agreed that
r holding a S
e end of Ju
ue, which is
espect of ot
and injuries
t years. The
the learni
special att
ws.
aken using
nd decision
a number
ved. This is
g an appro
od and poo
dentified.
d worked w
s death wer
process.
SCB) Regulatio‘advise the Aect of a Child med and therersons have wo
esult of a d
ccidental d
guarding Ch
t the circum
SCR.1 The I
une 2014.
being addr
her SCRs be
s of babies u
e SSCB Cha
ng and rec
ention to
g a ’system
s of practiti
of factors,
s the meth
ach that pr
or practice
with the fam
re asked to
ons 2006 requuthority and is known or se is cause for corked togethe
drowning a
eath.
hildren Boa
mstances su
ndependen
The reaso
ressed by SS
eing undert
under the a
ir therefore
commendat
the find
ms methodo
ioners occu
many of w
od recomm
rovides a th
occurs, so
mily or wer
o join a Rev
uires SSCBs totheir Board p
suspected: andconcern as toer to safeguar
3
ccident in
ard (SSCB)
rrounding
nt Chair of
on for the
SCB, but it
taken was
age of one
e directed
tion from
ings and
ology’, an
ur through
which are
mended in
heory and
effective
e working
iew Team
o undertake partners on d b) either – o the way in d the child.’
4
2.4 Agencies represented on the Review Team were as follows:
Amy Weir Lead Reviewer Jan Grey Chair of Serious Case Review Panel Lynne Thomas SSCB Business Manager Head of Safeguarding Sunderland CCG Lead Nurse Safeguarding STPCT NHS Foundation Trust Legal Representative Sunderland City Council Detective Inspector Northumbria Police Named Midwife for Safeguarding City Hospitals Sunderland Temporary Strategic Service Manager Sunderland People Directorate2 Lay Member SSCB
2.5 Each member of that team was asked to identify the frontline practitioners from their
agency who were known to, or had worked with, the family of Baby Penny. These
practitioners met to discuss their experience of the case.
2.6 The Practitioner’s Group was held February 2015. It was attended by a representative
group of those who had been involved.
2.7 The Lead Reviewer was commissioned to carry out this review in October 2014. Within
the first few months of the review, the SCR process, the role of the Lead Reviewer and
Review Chair and the functions of the Review Team and Practitioner Group were
shared and clarified.
2.8 The methodology adopted for the review and the opportunity to be an integral part of
a multi‐agency review process was still new to some of the professionals involved.
Whilst some reservations were apparent at the outset of the review, there was
general enthusiasm about the opportunity it afforded for identifying and
understanding factors that influenced the nature and quality of their work with this
and other families.
2.9 In this review, there were no individual conversations with practitioners. However,
two meetings were held jointly with the practitioners who had been involved. The
notes from these conversations together with key documents were the key
documents for consideration within the review.
2.10 Further information about the function of the SCR Review Team and the roles and
responsibilities of key groups can be found in Appendix 1 and Appendix 2. Comments
on the methodological limitations are attached in Appendix 3.
2.11 The formatting designed by a colleague, Linda Richardson, for previous SSCB SCRs has
been customised to report this review.
2 Previously Children’s Services and remains the term used in this report.
2.12
3
3.1
3.2
3.3
4
4.1
4.2
4.3
There was
being revie
Scope and
Taking a sy
than a pre‐
which arise
managers
around: th
completion
history and
There have
The Corone
accidental.
This review
Penny’s Mo
the bath.
Child’s Voic
Penny was
another ba
All the obs
fully immu
reviewed.
Mother pro
some evide
Penny’s Mo
Reviewer w
responded
services. Sh
family were
The CPN w
known her
There is a
involved in
she was bo
have a rela
some delay
ewed in Sun
Terms of R
stems appr
‐determined
e to drive th
or a review
he timelines
n, endorsem
d the consid
e been othe
er held an
w looks at ev
other discov
ce and the
a much wa
aby. Her M
ervations b
unised and
Penny’s ex
ovided. Alt
ence that th
other, AP h
was able to
earlier. Sh
he said she
e also helpf
was mentio
for more th
limited am
her care. H
orn. She to
ationship an
y in progres
derland.
eference
roach encou
d set of que
he key issue
w panel. Ke
ss of respo
ment and sh
eration of /
er parallel p
inquest in
vents that t
vered she w
Family’s Pe
anted baby
Mother prep
by professio
d her Moth
xperience w
hough, her
hey argued a
as been mo
o meet her
he gave a u
received a
ful. Penny w
oned as hav
han eight ye
ount of inf
Her Mother
ld us when
nyway; they
ssing the re
urages revie
estions from
es to be exp
ey lines of
onses to re
haring of as
/ role of fat
processes u
March 201
took place b
was pregna
erspective
y and her M
pared well f
onals of AP’
her ensure
was likely t
r Mother a
and this ma
ost distress
and to disc
useful acco
ll the suppo
was well loo
ving been
ears.
formation a
r refused to
we saw he
y met a co
view becau
ewers to be
m terms of
plored as op
f inquiry fo
eferrals and
sessments,
hers.
nder way d
5 and her f
between Jan
nt to the de
Mother (AP)
for the bab
’s care of P
ed that he
to have be
and Father
ay have had
sed by the d
cuss the re
ount of how
ort she nee
oked after a
particularly
about CP, P
o tell profe
er about the
uple of tim
use of the la
gin with an
reference.
pposed to th
or this revie
d threshold
the lack of
uring the c
finding was
nuary 2013
eath of Pen
) was very e
by and impr
Penny were
er developm
en positive
did not liv
some impa
death of Ba
view in Oct
w she was
ded from p
nd she was a
y supportive
enny’s Fath
ssionals wh
e review tha
mes and the
arge volum
n open enqu
This helps t
he preconce
ew quickly
ds, the tim
f full consid
course of th
s that the d
and May 2
nny from dr
excited to
ressed prof
positive. P
ment was
e given the
ve together
act on her.
aby Penny.
tober 2015
s supported
professiona
a very happy
e since Mo
her and ho
ho he was u
at they did
en she got
5
e of cases
uiry rather
the issues
eptions of
emerged
eliness of
eration of
his review.
death was
014, after
owning in
be having
fessionals.
Penny was
regularly
e care her
r, there is
The Lead
. She had
d by local
ls and her
y little girl.
other had
w he was
until after
not really
pregnant;
4.4
4.5
5 T
5.1
Backgro
5.2
5.3
5.4
3Names atime of B
she did not
he may hav
We know t
that he was
Penny’s Fat
The Family
The Family3
Mother ‐ A
Father ‐ CP Half‐siblingHalf‐sibling Baby Penny
ound Inform Prior to 200
pregnant w
period of s
admitted to
and he ass
children w
children w
Mother’s ca
Mother co
Community
discharged
GP. AP sto
content.
Father, CP
agency sea
have a hist
and some famBaby Penny’s d
t tell him s
ve found ou
hat he care
s looking af
ther was inv
y as known t
3
P
g 1 g 2
y
mation to 2
07, Penny’s
with her sec
significant m
o hospital a
umed care
were subjec
ere safe an
are.
ntinued to
y Psychiatri
by the me
opped takin
’s backgrou
rches were
tory of conv
mily details havdeath.
he was pre
ut earlier.
ed for Penny
fter her. CP
vited to me
to Agencies
2007‐2012
s Mother ha
cond child i
mental hea
as an inpatie
of their tw
ct to Child
nd they we
be support
c Nurse (CP
ental health
ng her med
und and h
carried ou
victions for
ve been chang
egnant until
y directly on
was written
eet with the
s
36 year
51 yea
16 year 7 years b. Augu
ad two child
in 2007, sh
alth problem
ent. She sep
wo children.
Protection
ere flourish
ted by men
PN), was pr
h service an
dication in 2
istory only
t as part of
violent crim
ged to preserv
two weeks
n some occ
n to and ask
Lead Revie
rs
rs
rs Lives Live ust 2013 d.
dren with h
e became v
ms includin
parated fro
Children’s
n Plans unt
hing and w
ntal health
rescribed m
nd she was
2012 and s
y became k
f the SCR sc
me and to h
ve anonymity.
s before sh
asions beca
ked to cont
ewer but he
es with Birthes with Birth
May 2014
her then par
very anxiou
g disturbed
m her partn
Services we
til it was e
ould not b
services un
edication. D
then regula
she appeare
known afte
oping proce
have been i
. The ages giv
he had Penn
ause her Mo
ribute to th
e did not res
h‐Father h‐Father
rtner. Whe
us and expe
d thoughts.
ner of fourt
ere involve
established
be returning
ntil 2012; s
During 201
arly review
ed to be s
er Penny’s
ess. He was
involved in
ven are the ag
6
ny though
other said
he review.
spond.
n she was
erienced a
. She was
teen years
d and the
that the
g to their
she had a
2, AP was
ed by her
table and
death as
s found to
domestic
es at the
7
abuse with his ex‐partner. However, this was not identified until the end of that
relationship.
5.5 It appears he became involved with AP at the end of 2012. He was registered at the
same GP practice as AP though they saw different doctors there. He was known to
mental health services and was prescribed anti‐depressants. AP did not tell him about
the pregnancy for several months. After Penny was born, he was involved in Penny’s
care, was seen by professionals and came to the house.
Period under review: January 2013 to May 2014
5.6 On a visit to her GP in January 2013, AP was surprised to discover that she was
pregnant. She stated that she had a partner but that they were not living together.
The GP, aware of her history and that she was vulnerable, discussed with AP
contacting a Psychiatrist to ensure she received the support she needed and she
agreed to this. At the end of January, a CPN contacted the GP and it was agreed that,
as Mother appeared to be stable and well, the Midwife should monitor her rather than
mental health services becoming involved.
5.7 The Midwife saw AP in mid‐January. She completed an Antenatal Vulnerability
Assessment Form and made a referral to the Vulnerable Adults’ Clinic for AP. The
Midwife was concerned that AP was vulnerable given that she had previously suffered
mental health problems when she was pregnant with her second child. She was also
aware that AP’s Mother had died in violent circumstances when AP was only 11 years
old.
5.8 At the beginning of April, AP was seen at the Vulnerable Adults’ Clinic and the
Obstetrician in attendance wrote to mental health services asking for her to be seen.
As a result, AP was assessed in early June by the mental health service; she was to
receive CPN support and contact was made with the Health Visitor.
5.9 Although AP seemed to be doing well and to be stable, the Midwife decided to discuss
with AP referring her and unborn Penny to Children’s Services. The Midwife, who had
known AP from her last pregnancy, made this referral at the end of April. She
suggested that an Initial Assessment was required given AP’s previous history of
mental health problems. AP continued to decline to name the Father of the baby. This
referral was not acknowledged and so she called Children’s Services on 20 May; she
was told the case had not yet been allocated. A week later the Health Visitor also
made a referral to Children’s Services saying she had a general concern given AP’s
history. Having still heard nothing, the Midwife called Children’s Services again at the
beginning of June when she was told that the case was still not allocated.
5.10 Finally on 13 June, the case was allocated and Mother was seen and an Initial
Assessment completed on 18 June. A meeting was held the next day with the
8
professionals involved – it was described by the Social Worker as an Initial Planning
Meeting; AP was present and she was said to be doing well. It was agreed that a Pre‐
Birth Core Assessment should be completed. On 26 July, a Pre‐Birth Core Assessment
Meeting was held. The assessment had been completed and the agreed outcome with
the other professionals was that Children’s Services should close the case as there
were no concerns. However, Children’s Services should be involved again, if and when,
the baby’s Father’s details became known. This Core Assessment was not recorded on
file at this time and so was not available to anyone looking at the case prior to Penny’s
death.
5.11 AP was regularly seen by her GP, CPN, Health Visitor and Midwife. She remained calm
and stable and was well prepared for the baby’s arrival. Baby Penny was born at the
end of August 2013 and was well and healthy. AP was happy and cared well for the
baby. The Midwifery visits and the Health Visitor’s primary visit went well and there
were no concerns. AP named Penny’s Father to the Health Visitor at her first visit but
following this disclosure, this information was not passed on. In October, when AP
attended for her post‐natal check with her GP she said that CP was caring for the baby.
The GP told AP that she would need to let Children’s Services know his name. The
Social Worker rang the GP a few days later but they agreed there were no apparent
concerns about CP and the case was not reopened.
5.12 During October and November, AP and the baby were regularly supported by the CPN,
Health Visitor and GP. AP seemed well and she reported being well supported by her
family and through daily contact with CP. In December she was a bit tearful and said
she was having relationship problems with CP and feeling low as a result. It appears
that CP was also experiencing depression and seeing his GP.
5.13 In mid‐January 2014, Mother spoke to the Health Visitor and said she was back in
contact with Father. She also said that Penny had had three episodes of stopping
breathing (apnoea), going blue and eyes rolling. AP was advised by the Health Visitor
to take her to the GP that day. The Health Visitor does not appear to have followed
this up directly but left it to Mother. It does not appear that Mother went to the GP till
a few days later about her own backache. During this consultation she mentioned the
apnoea stating that one of these episodes had occurred when the baby was being
looked after by CP. The GP referred the apnoea to a Paediatrician. He informed
Children’s Services about his knowledge of Father and that he knew CP was caring for
the baby ‐ recalling that an alert had been set up for this in the practice.
5.14 An ECG was carried out on Penny at hospital in mid‐February. The Paediatrician could
not identify any cause for the apnoea and decided to see her again in two months. AP
and CP went to the hospital together and were advised to reduce the amount of milk
they were feeding her as there were concerns that Penny’s recent weight gain had
been excessive.
5.15
5.16
5.17
5.18
5.19
5.20
6
6.1
AP was reg
well for th
agreed all w
GP had ha
Father som
were said n
In early Ma
arguments
had been w
excessively
of Penny st
At the end
involved. M
On the Sun
that Penny
the out‐of‐
under wate
was switch
The ambul
Police were
delay in th
reported to
The cause
result of ne
gave a deta
water whe
Penny at th
from AP a w
Areas of Sig
This section
Penny’s fam
questions w
were in pla
A key facto
are still pre
select and r
garded by t
e baby. In
was going w
ad no respo
me weeks ea
not to be av
arch, AP ran
with Penny
weepy for
y. AP also to
till seemed t
of April, the
Mother said
nday 18 May
y was unwe
‐hours GP t
er in the ba
ed off five d
ance’s arriv
e not infor
he arrival
o the Review
of Baby Pe
ear drownin
ailed accou
n she went
he time of t
week before
gnificant Pr
n looks back
mily and ex
were impor
ace at that t
or of a syste
esent and ho
review a sp
he Health V
February 2
well. The CP
onse from
arlier; he w
vailable.
ng the Crisis
y’s Father. T
a few wee
old the CPN
to be good.
e CPN close
she was fee
y, the day b
ll crying an
to continue
ath. Penny
days later. A
val was de
med by the
of the am
w Team.
nny’s death
ng. There w
unt of her a
to answer
the incident
e the incide
ractice (ASP
k at the act
xplores wh
rtant as the
time to sup
ems review
ow these ca
ecific case a
Visitor and
2014, the C
PN said tha
Children’s
was told tha
s Team sayi
The GP pre
ks. She said
that her re
.
ed the case
eling better
before Penn
d with loos
e to observ
was taken
AP and CP w
elayed thou
e Ambulan
bulance w
h is believe
were no ext
activities th
the door. I
t. When se
ent and he h
P)
ions and de
hy these pr
ey helped th
port good p
is also to co
an be chang
and to use t
CPN as con
CPN spoke
at she was i
Services ab
at there was
ng she was
escribed her
d Father w
elationship w
and menta
r.
ny fell in the
se stools; sh
e her. The
to hospital
were at the
gh it is no
ce Service
as fully inv
d to have b
ternal injur
at day. She
t is likely th
en by Polic
had not see
ecisions of p
ofessionals
he Review T
practice or
onsider whe
ged. The aim
this to prov
ntinuing to
to the Hea
ntending to
bout his re
s a new Soc
low in moo
r anti‐depre
was unreliab
with CP was
l health ser
e bath, AP c
he was subs
following d
l and put o
hospital.
t clear why
of this unt
vestigated
been a hypo
ies or retina
e said the b
hat AP was
e, CP stated
n Penny for
professiona
acted as t
Team unde
make poor
ether any sy
m of using a
vide ‘a wind
be stable a
alth Visitor
o close the
eferral in re
cial Worker
od because
essants; she
ble and was
s turbulent
rvices were
called NHS 1
sequently a
day AP fou
on life supp
y this was
toward inci
and the re
oxic brain i
al haemorr
baby slipped
not fully su
d that he h
r several da
als working w
they did. T
rstand wha
practice m
ystem vuln
a systems m
ow on the s
9
and caring
and they
case. The
elation to
r but they
of having
e said she
s drinking
. Her care
no longer
111 saying
advised by
nd Penny
ort which
the case.
dent. The
esult was
njury as a
hages. AP
d into the
upervising
ad parted
ays.
with Baby
The ‘why’
at systems
ore likely.
erabilities
model is to
system’.
10
6.2 From studying key documents and listening to the views and experiences of front line
practitioners involved in this SCR process, the Review Team identified five areas of
significant practice. These are listed below and are explained in more detail in later
sections.
ASP 1: Children’s Services: Timeliness of response to referrals from other Agencies
ASP 2: Managerial Oversight and Supervision, Timeliness of completion, endorsement and sharing of assessments
ASP 3: Opportunities to support through early intervention or CAF missed
ASP 4: Lack of full consideration of history and the consideration of / role of fathers
ASP 5: Context in which professionals were working ‐ Failure to escalate and
challenge effectively inaction by Children’s Services
6.3 ASP 1: Children’s Services: Lack of timely Response to Referrals
According to agency records, two referrals were made to Children’s Services between
April 2013 and May 2013, one from the Midwife, and one from the Health Visitor. The
Midwife first referred on 30 April 2013 and she chased this referral on four occasions as
she had had no response – 20 May, 28 May, 3 June and 13 June 2013. These referrals
were as a result of knowing the history of the family and Mother’s vulnerability during
the previous pregnancy. The GP also contacted Children’s Services in October 2013 and
January 2014.
6.3.1 Mother’s GP contacted Children’s Services in October 2013 by telephone and also in
January 2014 through a faxed letter with a follow up telephone call to chase a
response on 25 February 2014. In October the Social Worker called the GP about a
week later when it was agreed that action was not required as no concerns had been
identified. In January / February 2014 he did not manage to speak to the Social
Worker, being told that there was a new Social Worker who was not available to
speak. These referrals related to the alert on the GP system to say that Children’s
Services should be notified when the name of Penny’s Father was known.
6.3.2 There was no response to the 2013 referral for almost six weeks then an Initial
Assessment was completed followed by an Interagency Initial Planning Meeting. This
identified the need for a Core Assessment to be completed in compliance with the
Unborn Baby Procedure; this was completed and a meeting held on 26 July 2013.
However, the Core Assessment was not recorded on the system or shared with other
agencies until after Penny had died.
11
6.3.3 There was considerable frustration from the health professionals about the long delay
in response from Children’s Services. As Mother was pregnant and had not yet had the
baby it seems that the allocation of the case was not prioritised. The lack of
communication and response to the Midwife was a missed opportunity to share the
history and any concerns at the earliest possible stage and to put in place an effective
early response.
6.3.4 The referral from the Midwife was made following her completion of the Antenatal Vulnerability Assessment, which took into account past history and what was currently known about the family. The number of vulnerability indicators met led to the referrals to Children’s Services.
6.3.5. When eventually a Planning Meeting was held in mid‐June 2013, the health
professionals attended and so did Mother. There are minutes of this meeting and these are on the case record. The GP was asked for information at very short notice but did respond.
6.3.6. Even at this early stage Mother was reticent about naming Penny’s Father. This pattern
of her cooperating well and engaging with the professionals – apart from providing the name of Father – continued throughout. When she did disclose the Father’s name to the Health Visitor, this was not shared.
6.3.7. The GP contacted Children’s Services in October 2013 when he knew Father’s name.
The Social Worker did call back but it was agreed there were no concerns and Children’s Services would not become involved.
6.3.8. The GP faxed a letter of referral in January 2014 when Mother indicated that Father
was having sole care of the baby. The referral by the GP resulted in a telephone call more than a week later after the GP had chased it up. The GP was told that there was a new Social Worker who was unavailable. It was agreed with the Social Worker whom he spoke to that there were no specific concerns about Penny’s care. It does not appear that the risks Father may have posed, once his identity had been established, from his own history were identified or considered.
6.3.9. During the course of this review, the high level of demand on Children’s Services
became very apparent. The high turnover of staff and particularly of managers was also a concern. Three weeks after she had made the referral, the Midwife was told when she called that the case had not been allocated and she was given the same response two weeks later. Finally in mid‐June a Social Worker was allocated who made contact with her and the other professionals involved. The GP received one call but when she made contact in January 2014, she did not get an appropriate response.
6.3.10 The timescales for the completion of responses to contacts and referrals are clearly set
out in Working Together 2013. All contacts should be responded to within 24 hours but this did not occur in this case.
12
6.4 ASP 2. Managerial Oversight and Supervision, Timeliness of Completion, Endorsement and sharing of assessments
Managers have a responsibility to support frontline staff as well as a duty to monitor the effectiveness of the agency and its systems and to check that safeguarding responses are appropriately discharged. There is evidence in this case review, as in previous reviews, nationally and locally, that management oversight and supervisory processes were not robust in Children’s Services and the practice of frontline workers was not fully or consistently supported or challenged. Management oversight of practice and systems was inadequate in Children’s Services. Within other agencies – notably within Health – there was evidence of good supervision and management oversight as well as access to specialist support from in‐house safeguarding teams.
6.4.1 High quality reflective supervision is central to providing effective practice with families and good support for professionals working with families with complex needs. There is a great deal of research and literature to assist managers to develop high quality supervision across agencies4; the best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual families.
6.4.2 Supervision and managerial oversight for all key practitioners should identify poor
practice and examples where short cuts are taken to manage organisational demands. This case review revealed that there were several instances when the timeliness of the response to referrals was inadequate in Children’s Services. This was in breach of Working Together 2013 and the local SSCB procedures.
6.4.3 For the health professionals, there is evidence in this review that supervisory practices
were generally more robust in most cases in terms of supporting the practitioners or challenging practitioners when they were not persistent in following up concerns. However, it is not clear that the shortfalls in responses from Children’s Services were escalated at managerial level beyond the practitioners’ efforts by health services.
6.4.4 It emerged following the undertaking of an internal case audit in March 2014 that the
Core Assessment, said to have been completed at the end of July 2013, was not lodged on the electronic recording system and it could not be found. Although the Team Manager had been involved in the Initial Planning Meeting in June, the Team Manager clearly did not authorise or sign off the subsequent Core Assessment. It is highly likely that the plan to close the case was not agreed and discussed fully in supervision with the Social Worker. It is of note that no referral to early intervention services was suggested which would have been the likely supervisory advice rather than full closure and reliance on universal services plus mental health support.
4Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacott; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012.
13
6.4.5 As it appears that the Core Assessment was not written up until 2014 and, as no formal minutes were ever taken, other agencies relied on their notes taken at the meeting at the end of July 2013. Fortunately, these notes were available and were shared with some others who did not attend including the GP. Only by this means was the GP made aware of the need to contact Children’s Services to share information when Father’s name was known.
6.4.6 It has not been possible to discuss the shortfalls within Children’s Services with the
manager and practitioners directly involved. There has been a high turnover over of staff in those teams. Formal disciplinary processes have been undertaken in relation to some of the staff concerned. There was undoubtedly considerable pressure of work within Children’s Services which meant that not all assessments were checked and signed off by a manager. In a previous review of another case in the same time period, it was suggested that the volume of work restricted the amount of time the manager could spend on monitoring assessments and closure of cases. The recent Ofsted inspection in 2015 has also identified the high demand on the services as leading to shortcomings in the service.
6.5 ASP 3: Opportunities to support through early intervention or CAF missed
A Core Assessment was completed in June / July 2013. Although it was not appropriately recorded the Social Worker’s findings were shared at a meeting at the end of July 2013. The Social Worker’s recommendation was that the case should be closed whilst the Midwife and other universal services plus mental health services continued to support Mother. There are no formal minutes of this meeting. However, it does not appear that referral to a family support service or a Children’s Centre was considered or agreed.
6.5.1 In a case with such an extensive history and such significant parental vulnerability,
early intervention services and the completion of a CAF would have been beneficial and indeed, strongly indicated as a requirement for “stepping down” from social work intervention.
6.5.2 It appears that all the professionals present accepted that case closure was
appropriate. It is disappointing that other early intervention was not suggested, discussed or agreed. If a CAF had been in place this would also have provided a formal process for monitoring and reviewing what was happening in the case and for ensuring that joint working particularly across Adults and Children’s Services was well‐integrated. One multi‐disciplinary team meeting was held with the GP and others and this was good practice but there was no formal plan.
6.6 ASP 4: Lack of full consideration of history and the consideration of / role of fathers
Although Mother appeared to be highly cooperative and engaged well and proactively with professionals, she adamantly and consistently refused to provide the name of Penny’s Father until after the baby was born. Even then she appears to have not told all professionals consistently what the nature of their relationship was.
14
6.6.1 Many SCRs and the Biennial Reports written by Brandon et al have demonstrated that
the presence of significant males in families is often overlooked by professionals or given insufficient consideration. Although CP was believed not to be living in the family, he was nevertheless a significant adult in the life of Penny. CP appears to have been regarded as supportive, but at times, he was also a significantly negative influence for AP and probably Penny. AP described arguments and disagreements occurring on several occasions. AP said these disputes with him lowered her mood. On one occasion she said that he was drinking excessively and was then verbally abusive. He remained a risk that was not known and had not been assessed by anyone.
6.6.2 As identified in previous SCRs, nationally and locally, research advises that it a human
tendency to seek only the information that we ‘wish to find’, and the research confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without appropriate question or challenge.
6.6.3 In this case, Mother was cooperative on the face of it and demonstrated that she was
committed to the baby and made good preparations and provided good care once the baby was born. The baby thrived ‐ in fact she made significant weight gains which Mother was advised to consider in her feeding. However, although Mother did inform professionals that her relationship with CP was turbulent and caused her stress, there is a variation in the level of detail she discussed. CP’s relationship with Mother was said to relate solely to his involvement with Penny only and they did not live together. Mother did not identify Father till September 2013 – though this was not shared with the GP until later.
6.6.4 Mother shared some information about the nature of her relationship with CP from
October 2013. When she saw the GP in October she told the GP that she had left Penny in the care of CP. Later in October, she said to the CPN that she was seeing Father daily. In early December AP was tearful in a telephone call to the CPN saying she was having relationship problems with CP and on a visit later to the Mother she confirmed things were not going well. It was the CPN’s view that Mother’s upset and low mood were reactive to this situation when the Health Visitor called her to discuss the family.
6.6.5 In October 2013 and again in January 2014, the GP made contact with Children’s
Services about Father. There was a response on the first occasion to the GP but on the second occasion when the GP was concerned about Father having care of the baby there was no response or action taken.
6.6.6 When Mother contacted the Mental Health Crisis Team in early March 2014, she said
she was arguing with Father and feeling very low in mood in reaction to problems with Father. She said she had been weepy for a few weeks and that Father was drinking excessively and was being unreliable. There is no evidence that this further concerning information about circumstances which would have been having an impact on Penny were relayed to Children’s Services. Subsequently, Mother was prescribed anti‐depressants by the GP. At this same point, we now know that Father was seeing his
15
GP and was still taking anti‐depressants. In early April, Mother’s situation seemed to have improved and she was said to be feeling better.
6.6.7 Mother’s initial failure to provide information about Father meant that checks on his
background were not carried out at that stage. If they had been significant risks would have been identified. After Penny’s birth, she did disclose his name but by then it appears that an optimistic view – with some justification ‐ was taken because all appeared to be well. It was assumed this would continue. Even when new information came to light from the GP in early March, this did not prompt a new referral. This is not entirely surprising given the various frustrated efforts by the GP and others to achieve a response from Children’s Services during the history of this case. The failure by the Social Worker to undertake full checks on Father when the GP made contact in October 2013 was a missed opportunity.
6.7 ASP 5: Context in which professionals were working ‐ Failure to escalate and
challenge effectively inaction by Children’s Services
As identified in a previous review, practitioners were clearly working under a great deal
of pressure, both in respect of competing demands for time, and the fact that the
threshold for intervention was considered high. In previous recent SCRs conducted by
SSCB, the practitioners in the review process spoke about the impact of both,
commenting that high caseloads could easily encourage professionals to focus more on
their own individual responsibilities because multi‐agency working can appear to take
more time and maintenance. This high demand, pressure on staffing affected not only
Children’s Services but some of the other agencies involved in the case – particularly
Health Visiting.
6.7.1 Information from the Practitioners’ Group and the Review Team suggests that in this
Local Authority like others, there are diminishing budgets and competing priorities.
Research suggests that these factors along with pressures of work result in a tendency
to raise thresholds for access as the means of coping. In this case, there was
significant initial delay of several weeks in Children’s Services followed by a rapid
assessment and closure.
6.7.2 This view of Children’s Services “coping” and making do was endorsed by many of the
practitioners who contributed to this review and especially from colleagues in health
settings.
6.7.3 The Midwife and the GP were outstanding in their persistence to seek to get the
appropriate responses from Children’s Services. However, they were still frustrated at
times and it is not clear how or whether they sought to escalate concerns to a higher
level. This is an area for consideration by the SSCB.
6.7.4 In the circumstances of the Local Authority Children’s Services being under such
unrelenting pressure, high turnover of staff and organisational disarray, there was still
7
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17
Management of Systems 1. Managerial oversight is central to supporting critical thinking, challenge and
good assessments in multi‐agency work and this was not evident in some of the practice in this review
2. Lack of clarity about the function and titles of meetings; assessments were not all formally recorded and the notes shared leading to a lack of clarity and de‐prioritisation about what had been discussed and agreed
Professional‐Family interaction 3. Professionals were too focused on Mother’s cooperative engagement and did
not challenge her sufficiently to identify who Penny’s Father was. Her lack of disclosure of information about his identity was accepted as she justified it in terms of the casual nature of the relationship
4. Knowing the identity and background of, as well as the presence and role of males in families is critical to understanding family functioning and assessing risk
Multi‐Agency work 5. There were some good examples of joint working and information sharing
between the health professionals involved but there was a lack of robust multi‐agency collaboration from Children’s Services. At the same time, when Children’s Services were involved with the family, the decision to close the case and not to refer to early intervention services was agreed by all the other professionals involved
Use of Tools 6. The main risk tool used in this case was the Midwife’s Antenatal Vulnerability
Assessment. There was no multi‐agency risk assessment tools used and even the Core Assessment, which could have been used for this purpose, was not a joint effort involving all the professionals; we know it was not written up and shared for more than a year
Finding 1 Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi‐agency work and this was not sufficiently evident in this case. In this case there was evidence of managerial oversight and challenge in some key agencies
with specialist safeguarding advice and support in some cases. However, within Children’s
Services there was a considerable delay in allocating the case and referrers were not kept
informed. The Core Assessment by the Social Worker was not recorded on the system or
authorised by a Manager as required.
The impact of competing priorities and limited resources will always impact on service delivery
but it must also be recognised that times of transition are periods which increase risk and
18
require strong contingency plans from managers to ensure that vulnerable children are kept
safe and that staff are not left unsupported.
This finding was recognised by the Practitioners and the Review Team as being an
underlying issue in Sunderland and not unique to this particular review.
Finding 2 The function and titles of meetings were unclear; assessments were not all formally recorded and the notes shared leading to a lack of clarity and de‐prioritisation about what had been discussed and agreed. In this case, the pre‐birth Core Assessment meeting in July 2013 was not formally minuted. This meeting was important as it in effect set out the plan for ensuring that checks were made in relation to Father. Professionals were left to rely on their own notes of the meeting. As the Core Assessment was not written up or on the electronic system in Children’s Services, there was in effect no formal or informal record there of what had transpired and been agreed in that meeting. It seems likely that when the GP spoke to the Social Worker in October 2013 that without a formal reference to what was agreed in that meeting the Social Worker lacked clear terms and advice on the need to check out Father’s history rather than assume all was well with the care of the baby. This issue was also identified within another SCR in Sunderland. Finding 3 Professionals were too focused on Mother’s cooperative engagement and did not challenge her sufficiently to identify who Penny’s Father was. Her lack of disclosure of information about his identity was accepted as she justified it in terms of the casual nature of the relationship. Mother was present at both the interagency professionals’ meetings which were held in June and July 2013. In some ways this was good practice but it is likely to have limited the degree of challenge and the asking of important ”if“ questions about Father and any risks which may have presented. In a number of local reviews, attention was appropriately drawn to the need for some opportunity for professionals to share what ifs and questions without parents being present.
Finding 4 Knowing and understanding the identity and background of, as well as the presence and role of males in families is critical to understanding family functioning and assessing risk.
Serious Case Reviews have repeatedly highlighted failures by all professionals to effectively engage Fathers or significant males in the family and this was clearly evident in this review.
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20
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21
managers to share issues and discuss priorities across local services.
10.6 SSCB should in its next review of the effectiveness of early help / intervention, carry out an audit of outcomes for cases which are closed within Children’s Services to identify whether “step‐down” is being robustly managed through CAF and referral to early help services.
22
Appendix 1
The Serious Case Review (SCR) Review Team
Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date. One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Management Review Team. Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision‐making or supervisory role in relation to the frontline practitioners working with the family. Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process. Responsibilities of members of the Review Team
Represent their agency
Understand the broad details of the case under review
Ensure that a very broad outline chronology is undertaken
Identify key frontline practitioners who were known to the family
Undertake tasks related to data collection and analysis
Take ownership of the contents of the final report in presenting findings to the SSCB Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub‐committee, it’s function and purpose however, are different in that its’ work is solely to lead and work on a specific SCR. Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology.
23
Appendix 2
Roles and Responsibilities SSCB Chair
confirms the decision to hold a SCR
commissions on behalf of the Board, the Independent Reviewers
agrees to the model used and holds agencies to account for their active involvement in the process
ensures that there are sufficient resources in the SSCB Business Unit to support the SCR process
ensure Board partners are kept well briefed about the SCR and its progress
intervene where difficulties or barriers emerge from agencies SSCB Business Manager
is familiar with the model used and acts as a source of information for all who are involved in the SCR process. This can be a stressful and anxiety‐ provoking experience for those unfamiliar with this type of approach
ensures that all key parties are kept informed and there is formal sign up from all agencies involved in the SCR
convenes all meetings and ensures that these are well documented and minuted
works with and to the lead reviewers in terms of access to resources, data collection and contact with key individuals
ensures that steady progress of the SCR is maintained
keeps the SSCB Chair and the Board briefed about emerging issues and progress
manages issues about any parallel processes
acts as the key link between the SCR Review Team and the SSCB SCR Review Team Members will be expected to
attend all meetings where possible – deputies are not encouraged
collect documentation from own agency as and where required
read and analyse relevant data
undertake discussions with frontline staff from their own and other agencies if agreed and write up these ‘conversations’
support their own staff who are involved with SCR ensuring they receive full and appropriate support throughout the SCR process
Identify and facilitate changes within their organisation in response to any emerging practice or policy issues
meet /communicate with the staff at the end of the SCR process to discuss agency and professional learning
ensure that the required Learning and Reflection report is submitted for inclusion in the SCR final report
ensure that information about SCR process is communicated throughout their agency to managers and frontline practitioners
24
ensure required reports are submitted on time
read and contribute to draft and final reports
take responsibility for addressing any issues, which arise in their organisation in relation to the SCR, including any findings and recommendations
Practitioners Group members will be expected to
attend Practitioner Group meetings and/or
meet with two members of the Review team to discuss their views about working with the family and what factors helped and hindered your practice
reflect on their own practice and that of their agency
offer support and respectful challenge to other colleagues through their reflective and shared journey
read and comment on any draft report circulated by the Review Team
Lead Reviewers will
offer leadership to the Review Team, chairing meetings and ensuring key tasks are identified and followed through
work in partnership with Review team to ensure work is co‐ordinated and progressed
offer guidance and support to all individuals involved in the SCR process
maintain a reflective log to ensure that lessons can be learnt for future use of this model
produce draft reports for the Review Team, offering insights, analysis and challenge and take responsibility for the production of the final report on behalf of the team
ensure they have supervisory and mentoring opportunities to provide scrutiny and challenge to their role as lead reviewers
Rationale: The role of Business Manager is a vital one and it is essential that this individual understands the key part they play in supporting the SCR. Equally, others who are involved need to be clear about what is expected of them in this way of working. LSCBs may elect to appoint one lead reviewer to lead on the SCR and agree that the second lead reviewer can be an internal appointment from any of the agencies involved. It is important however to note that if this decision is taken, appropriate resources should be made available including external supervision for both reviewers.
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Appendix 3 Methodological Comments and Limitations
1. As several of the staff and managers who had been involved in the case – particularly in
Children’s Services – it was not always possible to seek the views of all those who had
been directly involved in the case.
2. The number of SCRs being undertaken in this Authority at the same time clearly impacted
not only on timescales but also on the workload and availabilities of the Review Team. On
occasions it also made it more difficult for the Review Team to separate one review from
another due to the similar nature of the case. However, the lessons emerging from this
Review corroborated those already identified and strengthened the messages for the
Board.
3. The Review Team have a better understanding of other agency’s learning through this very
interactive practitioner/Review Team relationship. Some of the learning enabled
individual agencies to better understand the role, function, and practice of their multi‐
agency partners in this case. It also challenged agency’s assumptions of one another’s
roles and statutory responsibilities. The experience of undertaking conversations with
frontline practitioners although time consuming was thought to be beneficial to the SCR
process.
4. Feedback from frontline practitioners indicated that they thought the Practitioners
Meetings, although not always comfortable, did help them better understand the role of
their colleagues and made a difference to their practice. They valued being involved as
key practitioners in the SCR process and thought this approach was more inclusive and
offered greater learning than previous models.
5. Overall, the experience was thought to be a positive one, but one which was not
necessarily any less time consuming than previous approaches.
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Appendix 4 Progress Report
Outlined below is some of the improvement work undertaken by individual agencies and by the SSCB partnership:
City Hospitals Sunderland NHS Foundation Trust
1. Invisible Fathers – Work is in progress to check GP records for father/significant others
where concerns are raised for any risk factors
2. Documentation supports a robust enquiry and assessment of mother ‐ The
Vulnerability Assessment Protocol document has been updated to strengthen the
focus on family dynamics. The updated Postnatal Records includes a section requiring
midwives to document who is present at each home visit. Used together these
improvements will assist midwives to better understand the support network for
pregnant mothers. Both will be implemented on 1 January 2016
3. Embedding improvements into everyday practice ‐ Group supervision has been
established for community midwives to ensure that the learning from this serious case
review is understood. The learning has also been disseminated through the
Directorate Safeguarding children group and within level three training for all staff so
group supervision will support enhanced reflective practice, learning and challenge
and the impact of this will be measured through a recently completed audit of the
records
Sunderland Clinical Commissioning Group
Practices to adopt a system appropriate to their practice to ensure up to date information on children that are subject to a plan, child in need or a looked after child in order to facilitate effective MDT meetings within the practice and information sharing between health professionals
GP practices have been given 2 examples of good practice of maintaining up to date information for discussion at MDT meetings
The examples also include suggestions of how to ensure the wider primary health care team are kept involved
Many practices already have a system in place for this
The importance of a good system with be re‐iterated through training, briefing documents and safeguarding newsletters
The impact of this will be reflected in practices feeling more confident of which families are known to be at risk and provide an agenda for a structured MDT meeting to discuss these families
Recommendations have been made that practices take minutes from MDT meetings and also add comments to relevant patient records as appropriate
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Multi‐Disciplinary Team (MDT) Meetings continue to be promoted to ensure vulnerable families are reviewed
An annual audit has been set‐up and was last completed in July 2015
This has resulted in a productive meeting with midwifery and an impending meeting with the lead for health visitors
Attendance at such meetings will continue to be monitored by each agency
Implementation of maintaining a spread sheet will aid in conducting productive MDT meetings
The impact of this will be audited as per the current annual audit cycle
Primary Care to understand the importance of father’s health information being used to inform assessments
Midwives will contact GPs where there are safeguarding concerns
This can only be done when the mother discloses information about the father
Midwives are currently updating their vulnerability assessment proformas, which
will be more in‐depth and share a more robust analysis of the family with GPs
South Tyneside NHS Foundation Trust (STNHSFT)
STNHSFT Safeguarding Children procedures and documentation are currently in the
process of being updated
Sunderland Safeguarding Children Board The SSCB has instigated the following improvement work:
Reviewed and updated the Safeguarding the Unborn Baby ‐ to strengthen the
requirement for the Pre‐Birth Child in Need Assessment to include information from
other professional assessments including the Vulnerability Assessment Protocol.
The assessment will therefore be multi‐agency and include the expertise of
partners. The Pre‐birth Child in Need Assessment must also be copied to all
professionals working with the family to ensure a shared understanding of what the
child’s plan is based on
Reviewed and updated the SSCB Vulnerable Baby Training ‐ This is delivered to
multi agency staff and includes the learning from SCRs
Raised awareness of the learning from the SCRs ‐ developed SCR briefing sheets
and delivered multi‐agency learning and improvement workshops. Staff attending
the sessions report that they have learnt from the sessions and are applying this to
their practice. The impact of this learning will be audited through a further post
course evaluation audit
The SSCB is currently implementing its Early help Strategy and will undertake an
audit in 2016 to understand whether “step down” is being robustly managed (see
10.6)
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Reviewed and updated the Child Protection/Child in Need Referral form
- To strengthen the requirement to access and consider historical family
information prior to submitting referrals
- To remind professionals that their responsibility does not end once they have
made a referral
- To remind professionals that they have a professional responsibility to
challenge drift/delay using the SSCB Escalation and Challenge Process when
required
- To require referring professionals to identify fathers and/or any other adult
male in the child’s life and clarify their role in relation to the child
The intended impact of the improvements is to ensure that referrals to Children’s Services contain robust historical information and a full outline of the family of a child including any adults they have contact with, remind multi‐agency staff of their responsibility to continue to work with families even if they have made a referral to Children’s Services and when multi‐agency professionals don’t receive a response to their referral or they don’t agree with the action taken in response to their referral they must escalate issues to ensure children and young people are safeguarded.
Reviewed and updated the SSCB Escalation and Challenge Function and
highlighted the process to multi agency staff ‐ The impact of this is to ensure that
multi‐agency frontline staff and managers are aware of their responsibility to
escalate issues of concern, the process is put into action when required and use of
the process safeguards children and young people
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Appendix 5 References relevant to this Review Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black ‐ Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003‐2005 Brandon M, Sue Bailey and Pippa Belderson ‐ Building on the learning from serious case reviews: A two‐year analysis of child protection database notifications 2007‐2009; DFE 2010 Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson ‐ University of East Anglia & University of Warwick – July 12: New learning from serious case reviews: a two year report for 2009‐2011 Core Assets – Children’s Safeguarding response to “why” questions raised in the SCR re Baby A and Child C May 2014 Department for Education – Working Together to Safeguard Children: A guide to inter‐agency working to safeguard and promote the welfare of children – 2013 DH 2011 Health Visitor Implementation Plan: A Call to Action DH Healthy Child Programme 2009 GMC ‐ Protecting children and young people ‐ The responsibilities of all doctors GMC 2013 NSPCC 2011 ‐ All babies Count Dual Diagnosis Nursing ‐ edited by G. Hussein Rassool (2006) Blackwell Tony Morrison Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003 Weir A and Douglas A (ed.1999) Child Protection and Adult Mental Health – Conflict of Interest? Oxford: Butterworth‐Heinemann Wonnacott, Jane; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012
