SERIOUS CASE REVIEW EXECUTIVE SUMMARY

In Respect Of

Child 1

Executive summary prepared by:-

Hester Ormiston, Independent Author

Signature:-

Executive summary endorsed by:-

Mike Tarver, Independent Chair of BSCB

Signature:

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  1. IntroductionPage 3
  1. Process of the reviewPage 3
  1. Summary of events that lead to the child’s deathPage 6
  1. Race, Language, Culture, Religion and DisabilityPage 6
  1. Background of the familyPage 6
  1. Overview of the serious case reviewPage 7
  1. SummaryPage 8
  1. Learning from the reviewPage 9
  1. Recommendations

9.1Summary of SCR RecommendationsPage 10

9.2Summary of IMR RecommendationsPage 10

9.3Summary of PCT Commissioning Health Overview Report Page 12

  1. Appendix:

Terms of ReferencePage 14

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  1. Introduction

1.1This report is a summary of the findings of a Serious Case Review (SCR) of how agencies worked together to provide services for the child who diedand his family. The SCR was conducted in accordance with government guidance Working Together To Safeguard Children 2010,which expects Local Safeguarding Children’s Boards (LSCB) give consideration to conducting a SCR:

When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family.

1.2The chair of Bolton Safeguarding Children Board, Mike Tarver, agreed soon after the death of the child concerned that a SCR should be convened because the circumstances indicated that abuse or neglect were suspected to be a factor in the child’s death. Ofsted had already been notified of the details of the child’sdeath from an unexplained cardiac arrest and that a Serious Care Review (SCR) may be held.

1.3The purpose of the SCR was to:

  • Establish what lessons are to be learnt from the case about the way in which local professionals and agencies work individually and together to safeguard and promote the welfare of children;
  • Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result and;
  • Improve intra and inter-agency working and better safeguard and promote the welfare of children.
  1. PROCESS OF THE REVIEW

2.1 The panel overseeing the SCR was chaired by an independent person, Vlasta Novak, who is an independent social care consultant. Vlasta has experience of management and inspection in the field of safeguarding. She has chaired several SCR panels.

2.2As part of the process, the panel discussed individual management reports (IMRs) prepared by each agency that had provided services to the family while they lived in Bolton. The panel ensured that each author of the IMRs had thoroughly examined the role of their agency and identified where lessons could be learned and things done differently in future.

2.3The panel comprised:

  • Vlasta Novak, the Independent Chair
  • Assistant Director, Bolton Children’s Services
  • Detective Inspector, Serious Case Review Team, Greater Manchester Police
  • Member from the Bolton Council of Mosques
  • District Manager, Bolton Children’s Services
  • Associate Director Safeguarding (Designated Nurse), Bolton PCT
  • Consultant Paediatrician, Designated Doctor for Safeguarding, Bolton PCT
  • Head of Personalisation & Inclusion, Adult Community Services
  • Housing Options and Advice Services Group Manager, Bolton Council Community Housing Services

2.4The panel met five times. The overview report was written by an independent author, Hester Ormiston, who attended each meeting of the panel. Hester Ormiston is a social care consultant who has management and inspection experience in relation to safeguarding services, and has written a number of overview reports. Working Together 2010 requires the author of the overview report to be a person who is independent of all the local agencies and professionals involved and of the LSCB.

2.5 At the first meeting, the panel agreed terms of reference (Appendix 1) which identified the main questions to be answered in each IMR and the Overview Report. Working Together 2010 asks that reports should not include details of children and family members to protect their identity.

2.6The review covered the time the family first lived in Boltonuntil the day the suggested cause of his death was known.

2.7The following agencies were asked to provide IMRs:

  • Bolton NHS Foundation Trust (to include midwifery, health visiting and Hospital 1)
  • General Practitioner services
  • Bolton Council Community Housing Services
  • Bolton at Home
  • Children’s Services Staying Safe and Children’s Centres (combined report)
  • North West Ambulance Service
  • North West Transport Service,and
  • A NHS Commissioning Health report drawing together findings from the five NHS reports

2.8Each IMR was written by a person who had not had any direct involvement with the family as a practitioner or practitioner’s supervisor to ensure the agency critically examined how services were provided. BSCB procedures expect a good standard of report writing, but offer comments from the panel to ensure this standard can be met. All the reports have been completed to a high standard in written styles which are clear and informative.

2.9The following agencies also had some information on the child’s family but the panel confirmed that it was brief and insufficient to merit an Individual Management Review (IMR). These agencies were asked to provide statements of involvement.

  • Greater Manchester Police
  • Adult Services Bolton
  • UK Border Agency
  • Children’s Legal Services Bolton; a summary of care proceedings

2.10Area 4 LSCB (where the child’s father had lived as a child, and his mother lived when she married into the family) was asked to provide information from each agency that had a record of the child’s father and his extended family, who lived at the same address. This included any information from records that may indicate the strengths and vulnerability of the child’s parents. The child’s older sibling was born while the family lived in Area 4. The information provided was very helpful in understanding more about the life of the family before their move to Bolton. Hospital 3 NHS Foundation Trust which had brief contact with the child was also asked to prepare a report.

2.11Following consultation with the police, the chair of the panel wrote through their solicitor to the child’s parents, and later to the aunt and uncle. The chair, with Bolton Safeguarding Board Officer, met the aunt to talk about the services offered to the family. She was positive about the services offered, especially the Children’s Centres, but considered more could have been offered in terms of general advice on caring for a baby and information on support available within the community. She made the point that the child’s family unusually was not living with the support of the extended family.

2.12Following endorsement by Bolton Safeguarding Children Board and in preparation for publication further engagement was undertaken with the family. Adult 1, Adult 2 and Adult 5 all had the opportunity to read the report in full before publication. In response to their feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that all dates, as well as gender references relating to the children would be removed from the report. It was agreed this did not detract from the learning.

2.13Adult 1 also wished to state she disputes the record that she was not happy with the second pregnancy. She has reported that this was a planned pregnancy, she was happy about this but she was unhappy with the circumstances between her and Adult 2. In response to this feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that this would be noted in the report but this is what she is believed to have said at the time.

3.SUMMARY OF EVENTS LEADING TO THE CHILD’S DEATH

3.1The childwas taken to the GP’s surgery in the afternoon. After the child had been examined the family were given advice and they returned home. Shortly after the return home, the child was found to be unresponsive. The mother ran into the road with the child and a neighbour rang for an ambulance. The same neighbour took the child into his own house and began cardio pulmonary resuscitation. The child was taken by ambulance to hospital and places on a life support machine but later died.

3.2The provisional post-mortem findings suggested that the child had suffered a fatal traumatic head injury. Neither parent had an explanation for the injuries at the time.

  1. RACE, LANGUAGE, CULTURE, RELIGION AND DISABILITY

4.1The immigration status of the child’s mother was that she had limited leave to remain in the UK when she arrived from Area 3 following her marriage. The family are Muslim with the child’s motherspeaking Urdu and Hindi. The child’s fatherwas born in Area 4 where his parents,who are UK citizens,still live. He has been in receipt of some disability benefits because he has a learning difficulty. Throughout the timescale of the review, with the exception of the Children’s Centre (where other parents attending spoke Urdu) both parents were observed to speak good English and did not need an interpreter.

  1. BACKGROUND

5.1The child’s father had lived in Area 4 from birth and it is known that he had some learning difficulties meaning that he was unable to read, write and communicate in line with his chronological age. The child’s parents were married in Area 3, with his mother joining his father at the family home in Area 4. After the child’s elder sibling was born the family found living with the extended family more difficult. They preferred to live separately and so moved to Bolton;living initially with other family members who had also moved there.

5.2With support from their relatives, they applied for and then moved into their own tenancy. The child who died was born eight months later.

6. OVERVIEW OF SERVICES

6.1The family received services during their time in Boltonfrom NHS community staff, health visitors and midwives, GP practice staff, Hospital 1 and the Tenancy Sustainment Service (a service offered to young adults to help them to maintain the tenancy) from Bolton at Home, their landlord.

6.2 Additionally the child’s sibling received services from some specialist NHS services because of some delayed development. The family kept appointments, worked well with staff from the different agencies and provided a good standard of care for their elder child.

6.3Bolton Children’s Services provide a universal Children’s Centre service to support families with young children to take part in activities with their children and to get support from mixing with other parents. The child’s mother attended two Children’s Centres. There were no concerns about the care given to her eldest child. Additionally the child’s mother attended a different Children’s Centre five times for her antenatal care during her pregnancy.

6.4 As the child’s mother became familiar with the NHS staff, she talked about some difficulties in the family, both practical and emotional. At times she indicated that she was lonely and would like to have support from her family in Area 3. Previously on one visit to the GP that the family was first registered with, the child’s mother had talked about her loneliness and some unhappiness both locally and when living with her husband’s family.

6.5 It would have been helpful if the earlier information had been known to the Community NHS staff. After the child’s birth, the midwife made a referral for family support but the referral could have been more complete, showing the family were receiving services from more than one agency.

6.6 The Children’s Centres oversee the process of providing family support, either informally, or within a formal plan. The local centre received the midwife’s referral for family supportwhen the child was about 2 weeks old. The referral did not indicate a high level of priority and so the service was planned to start a few weeks later, rather than more immediate support. The service, following the review, acknowledges that a Common Assessment Framework (CAF) should have been made so that all agencies could consider any additional support needs of the family.

6.7 When the child was taken to hospital by ambulance the services provided to the family were expert, prompt and sensitive. They took full account of the cultural and language needs of the family and treated them with respect at all times, even when explaining the need to follow procedures for an unexplained serious injury and eventually death.

6.8 A recommendation in the NHS commissioning report is how to manage an Acute Life Threatening Event (ALTE) for a baby or young child. All LSCBs have arrangements of what to do when a child dies from an unexplained injury or medical condition, but Hospital 3 has included within the procedure how to manage ALTE as well. The procedure includes timetabling notification to the appropriate police force, should it be necessary to secure a possible crime scene. In this case, notification to the police was delayed because of lack of clarity on whose role it was. This procedure is not used in all LSCB areas and not in Bolton.

7.Summary

7.1the narrative on each IMR and the responses to the Terms of Reference indicate that agencies worked competently, mainly meeting expected standards of practice and with an understanding and respect for the cultural identity of the family. Records describe a young couple who showed maturity, ability to manage the household, with a warm and caring approach to parenting.

7.2Most contact with the family was from staff from universal NHS services provided, but with increased support and specialist NHS services when assessments demonstrated the need.

7.3When the child’s mother used services at the Children’s Centres she was able to meet with other parents who spoke Urdu. Her attendance was not consistent, but this is an expected pattern with families encouraged to use the service when they want to.

7.4Housing services provided a prompt assessment of need, recognised when the family’s needs became more urgent and as part of the Successful Tenancy Plan (STeP) programme provided more support to maintain the tenancy because of their young age.

7.5When the child was in cardiac arrest, emergency services and both hospitals provided prompt, specialist, and sensitive care.

7.6The individual reports identify some occasions of poor or missed communication, but on the whole communication within and between services was good, and recorded in detail.

7.7The key area where, with hindsight, agencies acknowledge a better service could have been provided is an understanding of the context of the couple’s capacity to parent. Assessments did not complete the picture of the child’s mother needing more personal support and her possible acceptance of domestic abuse and the child’s father possibly needing more direct input to help him to parent because of his learning difficulty. Equally, except for housing agencies, it was not known for some time that the family had moved from a controlling atmosphere within the extended family.

7.8The panel discussed the level of need for family support demonstrated when, with hindsight; information from all agencies was combined into one list giving a fuller picture of possible vulnerabilities. There were some missed opportunities to give the child’s mother information and guidance on how to get more support from within the community. However panel agreed that even with the fuller picture, the family needs did not meet the threshold for intervention, or for a formal co-ordination of services using a Child Action Meeting (CAM).

7.9It is within this context that the panel concluded that the death of the child was neither predictable nor preventable and there was no indication of any risk of harm.

7.10The panel noted the difficulties for staff who have a responsibility to assess risk, but maintain a balance between support and respect for privacy in family life in the provision of universal health and family support services.

8.Lessons learned from this SCR

8.1the review has confirmed that the agencies provided good, prompt, sensitive services, taking account of the needs of the family. All observations of parenting were recorded and were consistent in noting a good standard of care. There was no concern by any agency and the review, with hindsight, has not identified any risk that could have been acted on at any time.