Inter-professional working task:

AJoin one of the professional groups –


Inter-professional working: Group task by Moira Dunworth, 2009, is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Social Work

1C&F Social Work,

2CJ Social Work,

Health

3Doctors,

4Nurses/Health Vistors


Inter-professional working: Group task by Moira Dunworth, 2009, is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

BRead this extract from the perspective of your allocated profession and form an opinion of the work of the profession in the case study. Explanatory notes have been added in [ ] where it might help with reading it as a stand-alone document. Social Workers are referred to as SW1, SW2 and so on.

CDiscuss the process of inter-agency communication:

  • Where was the power?
  • What is the origin of each type of power?
  • Where was the responsibility?
  • What kind of responsibility?

Extract from the O’Brien Report (2003) on the death of Caleb Ness

9.1 Inter Agency Discussions

We discuss this following the chronology of events.

a. Before Caleb Was Born

9.1.1 When Alec Ness [(father)] was in the Astley Ainslie [Hospital], the liaison between SW7 and CN, [an outreach nurse attached to the Astley Ainslie], was reasonably good, apart from SW7’s confused request for a prognosis, which we have already discussed. See 5.4.3 and 5.4.4.

9.1.2 When Shirley [mother] became pregnant, she probably had the pregnancy confirmed at the GP practice. We did not have her medical records, but when the GP gave evidence to us, he made reference to them and we know that by 17 April 2001, at least, she was receiving routine treatment there. The GP we interviewed was not the GP with whom she was registered: he apparently was not involved at any time. She moved round different doctors, when she did show up for appointments. We did not have the opportunity to interview them, or the people at the Simpson’s Maternity Pavilion who saw her for antenatal appointments. Again, we do not know the details, but it is clear that she was formally booked in, and she was being chased up by community midwives in the weeks before the birth. Unfortunately we did not have time to interview them. Yet none of these health professionals alerted the social work department to the fact that she was pregnant. It should be remembered that the GP records were full of communications from the CDPS [Community Drug Problem Service – an NHS service]: it was clear at once that this was a woman who had been in the grip of a very serious heroin addiction for two decades. The records of her previous pregnancies should have provoked questions about her existing children. The doctor treating Shirley at the CDPS knew of the pregnancy eventually. Yet there was no alert, even when neonatal abstinence syndrome was expected. Had it not been for the chance mistake which confused Shirley with someone who was about to be evicted, it is possible that Caleb might never have been on the CPR.

9.1.3 Pre-birth CPCCs are quite common, and in the ideal world, we would have expected one to have been arranged for Caleb in, say, early July. But this depends on Social Work involvement, preferably at an earlier stage in the pregnancy than May. The failure to communicate the fact of the pregnancy contributed to the rushed decision making in early August 2001, which was partly due to the need to decide where Caleb went when he was well enough to leave hospital.

9.1.4 From the point of view of good practice, we think that the health care professionals identified here should have communicated the fact of the pregnancy to the relevant social work department, given the critical facts that the mother had a serious and ongoing heroin addiction, and post natal abstinence syndrome was predicted for the baby. Obviously, this might have meant breaching the medical confidentiality of the mother, and we discuss this elsewhere. However, in fairness, we have to note that the Lothian Child Protection Guidelines then in force (5th edition) do not make such an expectation clear. On the contrary, the definition of “child”, which would imply a live baby after birth to a non-lawyer, and the whole approach in the section relating to “Agency Roles and Responsibilities – Health Service Staff “ (2.3), suggests that the drafters had in mind an actual child where abuse was suspected. The short reference to pre-birth case conferences at 8.11 adds nothing to amplify the guidance from the point of view of health professionals. In these circumstances, we do not criticise any of the health professionals involved prior to Caleb’s birth, and simply comment that it is unfortunate that none of them lifted a telephone to trigger some social work input. We assume that wherever possible, sharing of information takes place with the full knowledge of the parents involved. For the future, although the 6th edition of the Guidelines says more about pre-birth case conferences (8.12), the section on health care professionals has changed very little, and we therefore RECOMMEND that the section of the Child Protection Guidelines is amended to reflect the expectation that health care professionals will notify the social work department if they anticipate there may be risk after birth for a child still in utero, even if it means breaching the duty of confidentiality owed to either mother or father.

9.1.5 Good Practice should have led to direct communication by the social worker (SW4) with the appropriate health professionals. He did speak to Dr1, but it does not appear that he was speaking to either the primary care team or the maternity services in July. This would have enabled him to identify other areas of concern, such as Shirley’s failure to attend antenatal appointments.

b. While Caleb was in hospital

9.1.6 Shirley’s behaviour on the ward, when she was suspected of using drugs, was appropriately brought to the attention of the CPCC by the Midwife. However, she had left hospital before that, and after the CPCC she came into the hospital from home, and visited Caleb over a period of about twelve days. The nursing staff noted her appearance and behaviour on several occasions suggesting that she was under the influence of drugs. These observations were clear indications that she was using drugs in addition to her script, and they were therefore an important warning that she might be drowsy and incapable when she had Caleb at home. We were told that Nurse1 communicated this to the Hospital liaison health visitor, and the Hospital social worker. There the trail ended, as we accept that the information did not reach HV or SW4. Moreover, there is no written record in Caleb’s file, to show what happened. We RECOMMEND that a file entry is made when information is shared in this way, and in particular when liaison workers pass that information out beyond the hospital. We understand the procedure has changed since 2001, so that now Nurse1 would be free to telephone SW4 direct with similar information, and we welcome that change.

9.1.7 The hospital does not appear to have given the HV [Health Visitor] advance warning of Caleb’s discharge: she phoned the ward, only to find that he had just gone home. This is unacceptable when a baby is on the CPR. Moreover, the summary sheet sent to the HV was shockingly inaccurate, even to the point of saying the baby was a girl. (This refers to the “HV Liaison Summary”.) HosMan [a Consultant Paediatrician who is the Lead Clinician for Child Protection] made it clear that she was in despair about the inaccurate and duplicate record keeping, and we can only agree. We RECOMMEND that the LUH Trust reviews the accuracy of its record keeping for at risk children.

9.1.8 More significantly, there is no Community Paediatrics file for Caleb. No one remembered to refer Caleb to the Community Child Health Child Protection Service, which would have led to a file being opened, although this baby is exactly the patient envisaged when the LUH Trust reviewed its procedures. On one level, this is an internal failure, which seems quite extraordinary to us. Not one, but several, Trust employees actually attended a CPCC which decided to put Caleb’s name on the CPR, yet no one referred this case to its own Service. Why not? We leave it to the Trust to follow this up.

9.1.9 Yet there is an inter-agency dimension to this which is even more important. HosMan told us that she expected her office to be notified (in advance) when a CPCC was set up, such as Caleb’s, when the child was a patient in the special care baby unit. Not a single witness mentioned this to us. We asked every witness involved with Caleb’s CPCC who should have been invited to attend, in addition to those who had been invited. Not one mentioned the Child Protection Service. We went on to interview various senior managers in social work, asking them to tell us as a matter of theory and good practice who should have been invited to Caleb’s CPCC. Not one mentioned the Community Child Health (CCH) Child Protection Service in answer to that question, or in any other context. We interviewed the Child Protection Coordinator. He did not make a single reference to the Acute Trust’s Child Protection office. We spoke to a Consultant Neonatal Paediatrician about many issues, including recommendations for improvements in the future, particularly for babies with neonatal abstinence syndrome: again, no mention of the Child Protection Service. We could easily have finished our Inquiry without learning that the service existed. Something has gone badly wrong here, but it goes beyond our remit to discover what or why.

9.1.10 We can only conclude that inter-agency discussions between the Lothian University Hospitals NHS Trust, Lothian Primary Care Trust and the Social Work Department are woefully inadequate, and we RECOMMEND that serious dialogue is undertaken to clarify the role of the Trusts’ Child Protection Services within an interagency context. The Child Protection Co-ordinator, who must take some responsibility for this unacceptable muddle, should obviously be involved.

9.1.11 It follows from this that training will be needed, once the exact scope of the involvement of the LUH [Lothian University Hospitals NHS] Trust’s Child Protection Service is determined. The social workers who arrange CPCCs need to be clear when to invite a representative from the Child Protection Office to a CPCC. The nursing staff told us that they had received training since Caleb’s death, and were much clearer about what happens at a CPCC, and their own roles there, but there will be others who need similar training. On the basis of the limited evidence we have seen, Paediatricians and other senior medical staff who are likely to attend CPCCs are among them. It was not Neo1’s [Consultant Paediatrician witness] fault that SW4 arranged Caleb’s CPCC for a time when she was running a busy clinic, but it does not seem that it occurred to her to request a re-arranged time, although she was the one person who could have explained to the CPCC that Caleb had a much bigger problem than simply “not feeding very well”. Neo-natal abstinence syndrome should have been discussed carefully at Caleb’s CPCC, and this needed professional expert advice on what it meant.

9.1.12 HosMan was clear in her evidence to the Inquiry that there was a crying need for child protection training throughout the Trust, and we have no hesitation in backing her call for resources. We thought it was extraordinary that the Trust had gone to the expense of arranging a few training sessions, but not freed people up to attend them during their normal working hours. If inter-agency co-operation with the objective of creating an acceptable level of child protection in the Lothians is ever going to be achieved, staff at all levels need to know what is expected of them. We therefore RECOMMEND that Lothian Health ensures that its various Trusts fund the training requirements identified by their own senior staff with management responsibility for Child Protection.

9.1.13 Obviously, inter-agency discussions took place at the CPCC itself, and in the preparations for Caleb’s discharge from hospital, but we have said enough about that elsewhere. See Chapter 3 generally.

c. After Caleb left hospital

9.1.14 As we have noted, there was no Child Protection Plan. One would have thought that at some stage soon after the CPCC someone would have noticed this. SW2, for example, in supervising SW4, should have noticed and rectified the omission. She did not. There was no discharge review meeting, when SW4 and HV could have sat down and planned the frequency of home visits, and discussed the case generally. They did meet, when they visited Shirley – always by appointment-but not for re-evaluation of risk or proper discussion between themselves. The co-ordination between the two relevant agencies, social work and health, can only be described as poor. The responsibility for making the appropriate arrangements between himself and HV, as the case workers, lay with SW4, who had been nominated “Case Co-ordinator” at the CPCC. (see 6.5 of the Guidelines).

9.1.15 When HV decided that the risks were beginning to stack up, at the end of September 2001, she took the steps which were appropriate to trigger action. She notified SW4, she notified Dr1, and she knew that the GP already knew something of the situation. Having been told of Shirley’s post-natal depression, and her refusal of antidepressants, SW4 did nothing. When she went on holiday and arranged that SW4 visit Shirley while she was away, he did not visit. This is a lamentable failure in inter-agency working, and it unfortunately cannot be seen as an isolated lapse. The evidence of PCMan2 [Health Visitor manager], who manages all the Health Visitors in the region in connection with Child Protection matters, made it clear that that he was concerned at how often something similar happened in other cases, both where children had already been identified as being at risk, and even more where health visitors were attempting to highlight new cause for concern. (see 6.8.18). We RECOMMEND that the best means of triggering early reviews or immediate action in response to health visitors’ concerns be investigated, and improved upon, as a matter of urgency.

9.1.16 The CDPS [Community Drug Problem Service – an NHS service] did not realise what role the social workers expected them to play, even leaving aside the failure to circulate them with the Minutes. Even if the Minutes had arrived on Dr1’s desk within a fortnight, he would have thought he understood his role. He thought that his role was only to notify SW4 in the event of frank, unambiguous evidence of risk to Caleb himself.

9.1.17 What Dr1 did not appreciate was that the expectation was for a sharing of information about Shirley any time that there was an event which might have a bearing on Caleb’s safety. There is a difference, and it is a difference which is important in the provision of effective protection for our children. We cannot say exactly where the professional bodies would tell Dr1 to draw the line, but the advice from the General Medical Council quoted at 10.2.1 of the current Guidelines states: “if a doctor has reason to believe that a child is being physically, sexually or emotionally abused or neglected, it will usually require the doctor to disclose information to a third party”. Merely increasing the methadone prescription, or learning that Shirley was admitting to using more street drugs, might not create a duty of disclosure in the absence of some actual evidence that this might have an impact on Caleb’s care. Similarly, the knowledge of the GP that Shirley had developed post-natal depression, and further that she was refusing to take the drugs to ameliorate it, might not have been information which the GP could properly have disclosed direct to SW4 without her consent. We do not claim to know exactly where the line would be drawn, but we do consider that it is imperative that the social workers actually providing a system of child protection should know precisely what they can expect from their medical colleagues. Social workers and health workers have to be aware of the need to open up a channel of communication in every case. In this way, important information which does not breach confidentiality can be shared. We RECOMMEND that steps are taken to clarify when medical duties of confidentiality towards a patient who is caring for a child can be waived, and this must be undertaken as a matter of urgency. We believe that this is likely to be seen as a national issue which is not unique to Lothian.

9.1.18 There was a glaring failure of communication in the episode when SW9 from distant social work department telephoned SW4 to advise him that Shirley seemed to be utterly incapable, as a result of drug taking, on or about 7 September. How SW4 could ignore such a warning from a fellow professional is beyond understanding. We can only guess that he thought that he was much more experienced in drug related cases than she was, and was somehow relaxed about such an allegation. (He denied in evidence to us that this ever happened).