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Document title Unborn Protocol

Document description This protocol sets out guidance and locally agreed procedures for practitioners working with pregnant women in early help, health agencies and Children’s Social Care.

Document author Tina McElligott, Operational Director Family Services

Helen Swarbrick, Head of Safeguarding Named Nurse, Safeguarding Children, Royal Free London NHS Foundation Trust

Kate Clements, Named Midwife for Child Protection and Vulnerable Families

Karen Pearson, Head of Service, 0-19 Early Help

Version control

Document production date 25th June 2018

Document currency V1

Clearance process

Quality approver Date

Tina McElligott 25 June 2018

Release approver Date

Name of person who approves the document to be added to the Document Bank – this should be the Head of Service or above

Tina McElligott – Operational Director Family

Services

Date the document has been approved

26 June 2018

Family Services Barnet Unborn Protocol June 2018

Contents1. Introduction.......................................................................................................................... 3

2. Early Identification and Assessment.................................................................................3

3. Pre-birth planning................................................................................................................4

4. Risk Factors..........................................................................................................................44.1. Parental Factors..........................................................................................................................4

4.2. Teenage Pregnancy (under 18)..................................................................................................5

4.3. Teenage Pregnancy (under 16)..................................................................................................5

4.4. Late booking or concealed pregnancy........................................................................................5

4.5. Role of Health/Midwifery/GP Services........................................................................................6

5. Referral to Multi-Agency Safeguarding Hub (MASH)........................................................7

6. Child Protection Concerns..................................................................................................86.1. Strategy Discussion....................................................................................................................8

7. Assessment Outcomes........................................................................................................87.1. Child in Need...............................................................................................................................8

7.2. Child in Need of Protection.........................................................................................................8

7.3. Safeguarding Birth Plan..............................................................................................................8

7.4. Post Birth Planning......................................................................................................................9

8. Discharge Planning Meetings.............................................................................................9

9. Working with fathers/partners...........................................................................................11

Appendix 1 - Definitions and roles..........................................................................................12

Appendix 2 - Risk Estimation Matrix.......................................................................................17

Appendix 3................................................................................................................................20

Safeguarding Pre and Post Birth Plan Template...................................................................20

Appendix 4................................................................................................................................22

Pre-Birth Assessment and Intervention Timeline..................................................................22

Appendix 5................................................................................................................................23

Pre-birth Assessment and Post Birth Planning Guidance....................................................23

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Appendix 6................................................................................................................................29

Agenda Template for Discharge Planning Meeting...............................................................29

Appendix 7................................................................................................................................31

Discharge Form for Infants Placed in Foster Care................................................................31

Appendix 8 - Neonatal and Maternity Medical Report..........................................................32

Appendix 9 - Nursing Report...................................................................................................34

1. IntroductionThe National Maternity Review: Better Births 2016 recognises the need for an individual approach to every woman, pregnancy, baby and family. Young babies are particularly vulnerable to abuse, and work carried out in the antenatal period can help minimise the potential for harm through early assessment, intervention and support (Brandon et al 2016).

The success of pre-birth work lies in the quality of multi-agency involvement and partnership working and meaningful engagement and involvement with families. The family GP, the midwife, the health visitor are all critical roles in relation to vulnerable expectant mothers, alongside other statutory agencies and organisations working with family members.

In the vast majority of situations during a pregnancy, there will be no safeguarding concerns. However, in some cases it will be clear that a co-ordinated response is required by agencies to ensure that the appropriate support is in place during the pregnancy to best support and protect the baby before and following birth. It may also be necessary to consider the need for particular arrangements to be in place during and immediately following the baby’s birth.

This protocol sets out guidance and locally agreed procedures to practitioners working with pregnant women in early help, health agencies and Children’s Social Care settings with the purpose of ensuring every unborn baby in need of support and protection is safeguarded through multi-agency assessment, planning and decision making as early in the pregnancy as possible.

This protocol should be read in conjunction with:

NICE Guidance Antenatal and postnatal mental health: clinical management and service guidance

NICE guidance Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors

NICE guidance Pregnancy and complex social factors overview

Hidden Harm (HO 2003)

Appendix 1 contains details of definitions and roles.

2. Early Identification and Assessment

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/120620/hidden-harm-full.pdf

https://pathways.nice.org.uk/pathways/pregnancy-and-complex-social-factors

https://www.nice.org.uk/guidance/cg110




There is an expectation that all agencies working with pregnant women and expectant fathers are aware of the risk indicators for harm to an unborn child/newborn baby. Advice from maternity services and/or Children’s Social Care should be sought if any professional working with an expectant parent is unsure as to how an identified or suspected area of need or risk might impact upon an unborn or a very young baby i.e. substance or alcohol misuse, mental health needs and/or prescribed medication, learning disabilities/difficulties, domestic abuse.

In the early stages of the pregnancy, the Midwife must assess the strengths, risks and needs of the family and where there are concerns for the welfare of the unborn baby consider completing an early help assessment (EHA) referral in relation to the unborn child to ensure that services and TAC/TAF (Team Around the Child/Family meetings) are in place or where safeguarding concerns exist a referral to Children’s Social Care (CSC) is made.

An Early Help assessment (CAF) can support the development of a Team Around the Child/Family Plan, led by an early help/early years professional when additional help is required and there are no safeguarding risks present. The Team Around the Child/Family approach can swiftly mobilise support for pregnant women and expectant fathers to mitigate against future harm and optimise outcomes.

3. Pre-birth planning

The antenatal period provides a window of opportunity for practitioners and families to work together to:

form relationships with a focus on the unborn baby

identify risks and vulnerabilities at the earliest stage

understand the impact of risk to the unborn baby when planning for their future

explore and agree safety planning options

assess the family's ability to adequately parent and protect the unborn baby and the baby once born

identify if any assessments or referrals are required before birth; for example the use of the Common Assessment Framework (CAF) or alternative Early Help assessments agreed locally and the Peri-natal mental health check

ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s)

plan on-going interventions and support required for the child and parent(s)

avoid delay for the child where a legal process is likely to be needed such as Pre- proceedings, Care or Supervision Proceedings in line with the Public Law Outline.

Where professionals become aware a woman is pregnant, at whatever stage of the pregnancy, and they have concerns for the mother or unborn baby’s welfare, or that of siblings, they should NOT assume that Midwifery or other Health services are aware of the pregnancy or the concerns held.

Professionals should consider whether the newborn baby will be safe and if there is a realistic prospect of the parents/carers being able to provide adequate care throughout childhood. Where there is doubt, a pre-birth assessment may be required.

Each professional should follow their agency’s child protection procedures and discuss concerns with their safeguarding lead/named/designated professional for safeguarding.

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4. Risk Factors 4.1. Parental FactorsParental risk factors that may indicate an increased risk to an unborn child and which may mean that a pre-birth assessment is required:

involvement in risk activities such as substance misuse and alcohol

perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met

victims or perpetrators of domestic abuse

identified as presenting a risk, or potential risk, to children, such as having committed a crime against children

a history of violent behaviours

learning difficulties, severe physical or mental disability that significantly impede a person’s ability to provide care for themselves or others

historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have had children removed from parental care

currently ‘Looked After’ themselves or were looked after as a child or young person (care leavers)

a history of abuse in childhood

are teenage/young parents

recent family breakdown and social isolation/lack of social support

an inability to provide a secure and stable home base

female infant at risk of FGM

any other circumstances or issues that give rise to concern.

The list is not exhaustive and, if there are a number of risk factors present, then the cumulative impact may well mean an increased risk of significant harm to the child. If in doubt, professionals should seek advice about making a referral.

Appendix 2 contains a Risk Estimation Matrix; a useful tool for the assessment of risk.

4.2. Teenage Pregnancy (under 18) Being a young parent is not an automatic indicator of risk. However, the presence of some or all of the risk factors outlined in Appendix 1 will require further assessment. The midwife will refer all first time mothers,under the age of 20 and less than 28 weeks gestation to the Family Nurse Partnership.

4.3. Teenage Pregnancy (under 16) All pregnant teenagers under the age of sixteen will be referred to Children’s Social Care for a statutory assessment of need and risk. Practitioners should explore whether significant harm has occurred and undertake a statutory assessment of need in relation to the unborn child.

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4.4. Late booking or concealed pregnancyPregnant women with complex social factors are known to book later, on average, than other women and late booking is known to be associated with poor obstetric and neonatal outcomes (NICE 2010) [A concealed pregnancy is when a woman knows she is pregnant but does not tell anyone; or a woman appears genuinely not aware she is pregnant. Concealment may be an active act or a form of denial where support from appropriate carers and health professionals is not sought. This can become apparent at any stage of the pregnancy. Concealment of pregnancy may be revealed late in pregnancy, in labour or following delivery. The birth may be unassisted and may carry additional risks to the child and mother's welfare. A late booking is defined as presenting for maternity services after 20 weeks of pregnancy.Where there is a late booking or a concealed pregnancy the health practitioner should complete an immediate assessment in order to identify which agencies need to be involved and make appropriate referrals. In the case of a concealed pregnancy a referral must be made to Children’s Social Care.

4.5. Role of Health/Midwifery/GP ServicesHealth professionals, particularly midwives and GPs, are most likely to be in contact with expectant mothers and therefore in a key position to recognise risk factors. These health professionals are responsible for addressing the mother’s health needs and should share any relevant information with the network about any factors that may affect the mother’s parenting capacity. It is important that there is a mutual exchange of information across the network when there are concerns about any of these factors. When assessing risk, midwives should gather relevant information about the mother during the booking in appointment and consider whether any aspects of any of the following issues may have a significant impact on the child and if so, how:

social history

support from partners

family structure and support available (or potentially not available)

whether the pregnancy is planned or unplanned

the feelings of the mother about being pregnant

the feelings of the partner/putative father about the pregnancy

the mother’s dietary intake and any related issues

any medicines or drugs, whether or not prescribed, taken before or during pregnancy

alcohol consumption

smoking

previous obstetric history

the current health status of other children

any miscarriages or terminations

any chronic or acute medical conditions of surgical history

the mother’s mental health history

whether the mother has been subjected to Female Genital Mutilation and the unborn child, or any related child, is considered at risk.

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If the woman self refers to the midwifery team to book her pregnancy the GP should be notified and a health summary requested. This should then be sent to the hospital. This enables early identification of women who may have vulnerabilities and may need increased assessment and support.

If a family has been identified as being in need of additional support, the Health Visitor should be contacted and a targeted antenatal appointment arranged.

Health professionals can also contact social workers in the MASH team for advice on and individual cases can be raised at psycho-social meetings as appropriate.

The health professional providing care for a family should attend multi-disciplinary meetings as requested. In the event that he/she is unable to attend best efforts should be made for someone else within the team to attend in his/her absence. Reports should be completed for all case conferences and sent to the email provided.

To ensure best outcomes for the woman and her family, effective communication across the network is key. Contact details should be shared between the multi-disciplinary/multi-agency team to help facilitate this.

5. Referral to Multi-Agency Safeguarding Hub (MASH)

Referrals to MASH should be made as early in the pregnancy as possible, usually at 12 weeks when the pregnancy is confirmed as viable

If risks or needs change or become apparent in the course of an early help assessment or intervention, a step up meeting to Children’s Social Care should be convened without delay.

If in doubt, contact the Barnet MASH for a discussion, early referral allows Children’s Social Care and partner agencies to assess the family circumstances and make plans for intervention and support ahead of the baby’s arrival.

The MASH will determine which services are best placed to offer support. If a decision is made to progress to a statutory assessment of need, the assessment will determine whether the unborn baby will need to be afforded a Child Protection Plan, a Child in Need Plan or whether early help services can manage concerns.

In any of the following circumstances MASH will always progress the referral for a statutory social work assessment of need and risk to be undertaken:

current perinatal mental illness that presents a risk to the unborn baby

previous unexplained death of a child whilst in the care of either parent

a parent or other adult in the household is a person identified as presenting a significant risk, or potential risk, to children. This may be due to domestic abuse, violence, substance/alcohol abuse, mental health or learning difficulties

children in the household/family are currently subject to a child protection plan or previous child protection concerns and there has been no change in the family’s circumstances since the concerns were identified

a sibling (or child in the household of either parent) has previously been removed from the household temporarily or by Court order

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serious concerns about parental ability to care for the unborn baby once born or other children

maternal risk factors e.g. denial of pregnancy, concealed pregnancy, avoidance of antenatal care (non-attendance at or inaccessibility for professional appointments), non-co-operation with specialist services (i.e health visiting service) and non-compliance with treatment with potentially detrimental effects for the unborn baby

street homelessness/chaotic lifestyle

teenager under 16 years old

any other concern exists that indicate the baby may be at risk of harm.

6. Child Protection Concerns 6.1. Strategy Discussion If there is reasonable cause to suspect an unborn baby is likely to suffer significant harm, a Strategy Discussion will be convened. This will be co-ordinated and chaired by Children’s Social Care who will involve the Police and Health professionals, other professionals involved with the family may also be involved.

The strategy discussion will determine if there is evidence of risk of significant harm. Where risk is identified a s47 enquiry will be initiated either jointly with Children’s Social Care and Police Child Abuse Investigation Team or Children’s Social Care as a single agency investigation. The s47 enquiry will seek to ascertain the level of and source of risk to the unborn baby and any other children in the family and set out in a Child and Family Assessment.

7. Assessment Outcomes 7.1. Child in Need If the assessment determines that there is no risk of significant harm but additional support is required Children’s Social Care will agree with the family and other agencies, a Child in Need (CIN) Plan with clear actions and outcomes to be achieved within timescales. The CIN Plan will be regularly reviewed with the family and multi-agency team to monitor progress being made.

7.2. Child in Need of Protection If the assessment determines that there is sufficient concern of the likelihood of current or future significant harm, a pre-birth or Initial Child Protection Conference will be convened by Children’s Social Care to ascertain whether the unborn baby requires a Child Protection Plan to safeguard their welfare. The Initial Child Protection Conference must take place no later than week 30 of the pregnancy.

7.3. Safeguarding Birth Plan Children’s Social Care are responsible for ensuring the multi-agency partnership formulate a plan to safeguard the baby at birth, together with the Named Midwife for Safeguarding. The Safeguarding Birth

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Plan should detail the planning for delivery and the immediate post-natal period, including who will be notified upon the birth of the baby. The Plan will identify the roles and responsibilities of the professional network around the unborn baby and family. The safeguarding birth plan must be disseminated to relevant professionals and relevant birthing units including the Emergency Duty Team (out of hours social care). The safeguarding birth plan should include contact numbers and names of professionals involved and the agreed arrangements for where the baby, once born, is to be discharged.

It is the responsibility of the Named Midwife for Safeguarding Children or the midwife from the complex social needs team who attends the CIN/Core group meeting to ensure that other health practitioners involved are informed of the safeguarding birth plan i.e obstetrician, neonatologist, GP, Health Visitors (HVs).

The Safeguarding Birth Plan should be shared with parents unless to do so is felt to put the mother or baby at increased risk of harm. Professionals will need to agree how the plan will be shared with parents.

Appendix 3 provides a template for practitioners to record the information required for Pre and Post Birth Safeguarding Planning.

7.4. Post Birth PlanningFollowing the birth of the baby, a need for a longer stay in hospital may be necessary, particularly when there are medical needs. The professional network will need to agree how risks and needs are managed during this period; this may include issues relating to parental contact with the baby, feeding, supervison and visitor restrictions.

Where an assessment has determined that the baby will be at immediate risk of harm at birth, Children’s Social Care will make arrangements for the baby to placed in alternative care and may apply to the Court for the baby to be placed away from the birth parents. This may delay discharge from hospital and discussions should take place between Children’s Social Care and the Hospital to agree timescales, contact arrangements and the management of risk during this period.

The social worker is responsible for conveying to the parents, decisions about the separation of children from their care. In most situations this will have been discussed ahead of the birth and the parents will have had an opportunity to seek legal advise and representation.

Appendix 4 contains a timeline for pre-birth assessment and intervention.Appendix 5 provide guidance on pre-birth assessment and post-birth planning.

8. Discharge Planning Meetings

The discharge planning process should be initiated as soon as the mother is admitted or presents for delivery and all Midwives caring for her should have full access to and knowledge of the Safeguarding Birth Plan.

Midwives have a safeguarding responsibility to all babies and will ensure that any protective action required within the hospital setting is managed following birth of the baby.

The discharge plan will set out where the baby is to be discharged to, if not to parental care.

Where babies are subject of a Child Protection Plan they should be delivered within the hospital setting and a Discharge Planning Meeting must take place before the baby leaves.

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The following agencies must be invited to attend Discharge Planning Meetings (to be coordinated by midwifery staff/safeguarding leads and the Social Worker) and should be represented in order for the meeting to proceed:

Children’s Social Care Team Manager/Social Worker

Paediatric Consultant (or specialist registrar/Neonatal Nurse Practitioner) where there are medical concerns with the baby

Named Nurse/Midwife Safeguarding Children or representative

other relevant hospital staff involved in the care of the child/family

health visitor.

Other agencies may need to be involved in cases and attendance should be considered such as;

Named Nurse/Safeguarding Children Nurse Community Trust

School Nurse

Police

Mental Health colleagues

Learning Disability colleagues

GP

Drug/alcohol agency

Domestic abuse services and;

any other key professionals that are in a position to support the safeguarding of the newborn.

If care proceedings have been initiated prior to discharge the Children’s Guardian must be invited and consideration given as to whether legal representatives should attend.

Children’s Social Care will lead the Discharge Planning Meeting where there is a Child Protection Plan in place.

An agreed multi-agency discharge plan will set out arrangements for the care and safety of the child following discharge from hospital into the community and will include actions, timescales and responsibility for actions, including:

details of the child’s GP. Parents should be encouraged to register their baby with GP as soon as possible and inform professionals who this is likely to be

additional medical investigations requested including timescales for completion

documentation of any legal orders in relation to this child (with copies filed if available).

The Social Worker will ensure that the parents and any support person they choose will be informed when and where the meeting will take place.

Where a baby is born prematurely it is reasonable to plan the discharge meeting 7 – 10 days prior to the earliest likely discharge date. All agencies should aim to agree the baby’s discharge as soon as safely and practicably possible.

It is preferable that newborn babies are not discharged at a weekend or on a bank holiday unless there is a consensus of opinion that it is safe and reasonable to do so and that sufficient midwifery/health visiting services are in place during this period to monitor the immediate period following. However, consideration must be given to demand for acute medical beds on the Maternity Unit and on the

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Neonatal Intensive Care Unit particularly if the newborn has no acute medical needs. This must be documented in the child’s medical record and discharge plan.

The Discharge Planning Meeting must be fully documented and the minutes and agreed plan stored in the child’s records under documents. A copy of this can be shared between the professionals attending the meeting and the parent(s). In addition, a copy should be sent electronically to [email protected].

Appendix 6 provides an agenda for the Discharge Planning Meeting. Appendix 7 contains a template for infants placed in foster care.

Appendices 8 and 9 contain report templates to be completed by the medical and nursing teams regarding neonatal and maternity medical information where there are safeguarding concerns about a newborn.

9. Working with fathers/partners

Fathers play an important role during pregnancy and after. The National Service Framework for Children, Young People and Maternity Services (2004) states:

‘The involvement of prospective and new fathers in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father is resident or not. Pregnancy and birth are the first major opportunities to engage fathers in appropriate care and upbringing of children’ (NSF, 2004).

It is important that all agencies involved in pre and post-birth assessment and support fully consider the significant role of fathers and wider family members in the care of the baby, even if the parents are not living together and, where possible, involve them in the assessment. This should include the father's attitude towards the pregnancy, the mother and newborn child and his thoughts, feelings and expectations about becoming a parent.

Information should also be gathered about fathers and partners who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified.

A failure to do so may mean that practitioners are not able to accurately assess what the mother and other family members might be saying about the father's role, the contribution which they may make to the care of the baby and support of the mother, or the risks which they might present to them. Background police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Involving fathers in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered, especially if they are non-resident fathers and not living within the family home.

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mailto:[email protected]


Appendix 1 - Definitions and rolesDEFINITIONS Word or Phrase

Concealed Pregnancy A concealed pregnancy is when:

a woman knows she is pregnant but does not engage with appropriate services

a woman appears genuinely unaware she is pregnant.

Concealment may be an active act or a form of denial where support from appropriate carers and health professionals is not sought.

Concealment of pregnancy may be revealed:

late in pregnancy (after 34 weeks)

in labour

following delivery. The birth may be unassisted and may carry additional risks to the child and mother's welfare.

Delayed or Late Booking a late booking is defined as presenting for maternity services after 20 weeks of pregnancy

the pregnancy may be undetected where both the mother and her health care providers are unaware that she is pregnant

it may be a conscious concealment where the mother is aware of her pregnancy and is emotionally bonded to the unborn baby but does not tell anyone

the pregnancy may also be denied, this may be conscious denial where the mother has physical awareness of her pregnancy, but lacks emotional attachment to the foetus, or

unconscious denial where the mother is not subjectively aware of her pregnancy and genuinely does not believe the signs of pregnancy or even the birth of the baby (e.g. Psychotic delusion).

Multi-Agency Safeguarding Hub (MASH)

The MASH is a team including Police, Health, CSC and other agencies (depending on local arrangements). The

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benefit is that they can share information quickly and make decisions as to the required level of intervention

Child Protection-Information Sharing (CP-IS)

CP-IS is a nationwide solution that connects local authority children’s social care systems with those used by NHS unscheduled care settings. It enables the exchange of key child protection information and episodes of unscheduled NHS care.

Roles And Responsibilities The definition of the roles and responsibilities of those involved, social care, health workers, police and other professionals, are informed by the Children Act 1989 and the statutory guidance as given in ‘Working Together to Safeguard Children; 2015’.

It is the responsibility of all professionals to:

work to statutory guidance

understand and work to the guidance in this document

understand and work to their own profession’s guidance.

And particularly to:

share information in an appropriate and timely way

refer – not assume that another professional has done so - and escalate issues as necessary

engage in ‘Early Help’ and ‘Children in Need’ processes for cases below the section 47 threshold

respect the view and roles of other involved professionals

consider risk of Child Sexual Exploitation (CSE) and other Sexual Crime.

Children’s Social Care (CSC) and Social Workers accept referrals from other professionals

work to the published Continuum of Help and Support document published by Barnet Safeguarding Children Partnership

make enquiries and decide if any action must be taken under section 47 (s47) of the Children Act 1989. An unborn child may be subject of s47 enquiries

decide within one working day the type of response a referral requires

give feedback on referrals taken

lead assessment processes where social work thresholds are met

make clear to families how a social work led assessment will be carried out and when they can expect a decision on next steps

ensure assessment is fully informed by the views of other professionals

initiate strategy discussions to decide on s47 thresholds where this is necessary

convene an Initial Child Protection Conference for the unborn/newborn child if thresholds are met

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social worker will be the Lead Professional for any case where a Child Protection Plan is in place.

Healthcare StaffHealthcare staff must consider the needs of the unborn baby including whether there could be child protection risks after birth. Within the United Kingdom, the law dictates that there is a difference between an unborn and a newborn baby (European Council on Human Rights, 2008) and decisions in regards to the unborn baby therefore also need to take account of the needs and rights of the woman.

This protocol is intended for use by all health professionals and in particular staff who provide care to pregnant women and their families, namely Midwives, Health Visitors and Family Nurses. However, Midwives have a significant role in identifying risk factors to the unborn/newborn baby during pregnancy, birth and the post-natal period both in hospital and the community. Midwives are the primary health professional working with and supporting women throughout pregnancy. The relationship they foster with the pregnant woman provides an opportunity to observe attitudes towards the developing baby and identify potential problems during pregnancy, birth and the child’s early care.

All pregnant women will have a named midwife who will:

identify pregnant women where existing risk factors may impact on the wellbeing of the unborn/newborn baby and where additional support or protection is required

identify the need for early intervention when planning care by undertaking an early help assessment where appropriate

plans care for the woman and her unborn baby, with the wider maternity team as required, and records the details of this in the woman’s hand held maternity notes

effective inter/intra agency sharing of information, assessment, co-ordinated joint working and care planning for pregnancy and the immediate postnatal period

ensure the views of the parents are sought and are involved and informed in all decisions that affect them

coordinate the health care from confirmation of pregnancy, including the wellbeing concerns for the unborn baby until hand over to the health visitor or family nurse as the named person

consider risk of Child Sexual Exploitation (CSE) and other sexual crime

identify Female Genital Mutilation (FGM and refer according to mandatory processes.

During the childbirth continuum it may be necessary for health professionals to refer to CSC.

MidwivesIf an appointment is made very late for antenatal care (after 20 weeks of pregnancy), the reason for this must be explored. If there is a cause for concern a referral should be made to the relevant CSC department. CP-IS should also be checked. The woman must be informed that the referral has been made, unless there are significant child protection concerns that prevent you from doing so.

If a woman arrives at the hospital in labour or following an unassisted delivery, where a booking has not been made, a referral should always be made to the relevant CSC department by the midwife or other appropriate person. CP-IS should also be checked. The baby should not be discharged from hospital until a strategy discussion has been held and/or relevant assessments undertaken. *NB Health Professionals have no legal right to stop a woman self-discharging along with her baby. The Midwife or

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appropriate person must immediately contact the Police in these circumstances and subsequently, notify CSC.

If the baby has been harmed in any way, or abandoned, as a result of the mother’s actions (or non-action) a referral must always be made to the police by the midwife, or appropriate person.

Health Visitors/Family NurseIf the Health Visitor (HV) encounters a woman that they believe to be pregnant, and they also believe that woman has not sought health advice, they should encourage her to seek support from a Midwife and/or GP.

If the woman refuses all attempts to persuade her to seek health advice the HV/Family Nurse (FN) should make a referral to CSC.

It is best practice to discuss the circumstances of the woman with the Midwife, GP, FN Supervisor, School Nurse, as appropriate and the Named Nurse/Midwife for Safeguarding.

Always remember that HV/SN should ensure they make ante-natal contact with the mother, as a priority, particularly where there are safeguarding concerns.

School Nurses (SN)The School Nurse may well be able to help a child who is pregnant to accept that she needs support. If possible, having gained consent from the child, the SN should liaise with the G.P and Midwife to consider a way forward. If faced with denial or refusal to seek medical attention the SN should make a referral to CSC.

General Practitioners (GP) It is good practice to refer all pregnant women to a midwife as soon as possible, in order that the most appropriate care is given.

Where a GP has significant reason to believe a woman is pregnant, but she refuses all attempts to persuade her to undertake further investigations, further action needs to be taken.

This should include discussion with the Midwife, HV/FN or School Nurse (as appropriate). It may also be helpful to discuss the concerns with the Designated Doctor or Named GP for Safeguarding Children. If the woman refuses all attempts to persuade her to seek health advice the GP should make a referral to CSC (see section 6 and 7) .

Substance Misuse Specialist If a pregnant woman and/or her partner is known to the local Substance Misuse Service a referral should be made to the Drug and Alcohol Team who will follow maternity pathways. Referral to CSC should be considered using the relevant assessment tool.

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Mental Health and Learning Disability Specialists When working with a pregnant woman and/or her partner who has mental ill health or learning disabilities, professionals in these services should encourage these women to access early ante-natal care and support. Professionals working in Mental Health or with clients with learning difficulties may be well placed to support the woman given the therapeutic relationship with her.

It is imperative that Learning Disability or Mental Health specialists support other professionals in their assessments to ensure the needs of the woman are fully understood.

Role of Specialist Safeguarding Children Team in Acute Hospitals Where the unborn baby is subject to child protection planning, it is the responsibility of the Social Worker with core group members to develop the Child Protection plan and disseminate to agreed partners and relevant birthing units.

The detailed Pre and Post Birth Plan will be developed at 34 weeks gestation or at the earliest opportunity once agencies aware of the pregnancy. The plan will be disseminated to relevant professionals and include contact numbers and names of professionals involved and the agreed discharge arrangements.

Role of other Professionals/Agencies For those professionals not specifically identified within the protocol where there are concerns regarding an unborn/newborn baby a referral should be made into the MASH .

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Appendix 2 - Risk Estimation Matrix

The matrix has been taken from an adaptation by Martin Calder in 'Unborn Children: a Framework for Assessment and Intervention' of R Corner's 'Pre-birth Risk Assessment: Developing a Model of Practice'.

This matrix is to be used as a tool and is not intended to provide a comprehensive analysis of risk.

Factor Elevated Risk Lowered Risk

The Abusing Parent

negative childhood experiences, inc. abuse in childhood; denial of past abuse

violence abuse of others

abuse and/or neglect of previous child

parental separation from previous children

no clear explanation

no full understanding of abuse situation

no acceptance of responsibility for the abuse

antenatal/post natal neglect

age: very young/immature

mental Disorders or illness

learning Difficulties

non compliance

lack of interest or concern for the child.

positive childhood

recognition and change in previous violent pattern

acknowledges seriousness and responsibility without deflection of blame onto others

full understanding and clear explanation of the circumstances in which the abuse occurred

maturity

willingness and demonstrated capacity and ability for change

presence of another safe non-abusing parent

compliance with professionals

abuse of previous child accepted and addressed in treatment(past/present)

expresses concern and interest about the effect of the abuse on the child.

Non-abusing parent

no acceptance of responsibility for the abuse by their partner;

blaming others or the child.

accepts the risk posed by their partner and expresses a willingness to protect;

accepts the seriousness of the risk and the consequences of failing to protect;

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willingness to resolve problems and concerns.

Family issues (marital partnership and the wider family

relationship disharmony/instability

poor impulse control

mental health problems

violent or deviant network involving kin, friends and associates (including drugs, paedophile or criminal networks)

lack of support for primary carer/unsupportive of each other

not working together

no commitment to equality in parenting

isolated environment

ostracised by the community

no relative or friends available

family violence (e.g. spouse)

frequent relationship breakdown/multiple relationships

drug or alcohol abuse.

supportive spouse/partner

supportive of each other

stable or violent

protective and supportive extended family

optimistic outlook by family and friends

equality in relationship

commitment to equality in parenting.

Expected child special or expected needs

perceived as different

stressful gender issues.

easy baby

acceptance or difference.

Parent-baby relationship

unrealistic expectations

concerning perception of baby's needs

inability to prioritise baby's needs above own

foetal abuse or neglect including alcohol or drug

realistic expectations

perception of unborn child normal

appropriate preparation

understanding or awareness of baby's needs

unborn baby's needs

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abuse

no ante-natal care

concealed pregnancy

unwanted pregnancy

identified disability (non- acceptance)

unattached to foetus

gender issues which cause stress

differences between parents towards unborn child

rigid views of parenting.

prioritised

co-operation with ante-natal care

sought early medical care

appropriate and regular antenatal care

accepted/planned pregnancy

attachment to unborn foetus

treatment of addiction

acceptance of difference- gender/disability

parents agree about parenting.

Social poverty

inadequate housing

no support network

delinquent area.

Future Plans unrealistic plans

no plans

exhibit inappropriate parenting plans

uncertainty of resistance to change

no recognition of changes needed in lifestyle

no recognition of a problem or a need to change

refuse to co-operate

disinterested and resistant

only one parent co-operating.

realistic plans

exhibit appropriate parenting expectations and plans

appropriate expectation of change

willingness and ability to work in partnership

willingness to resolve problems and concerns

parents co-operating equally.

Appendix 3

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Safeguarding Pre and Post Birth Plan Template

Safeguarding Pre and Post Birth Conference

Name: MRN:

Address: GP:

Date of Birth: EDD:

Telephone Number: Parity:

Brief Medical History: Brief Obstetric History:

Medication: Concerns:

NHS Number: Plan completed by:

Named Contact: Telephone Number:

Summary of Concerns:

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Plan1.

2.

3.

4.

5.

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Appendix 4 Pre-Birth Assessment and Intervention Timeline 6-12 weeks Booking appointment with the Community Midwifery service. Where appropriate

and in accordance with Barnet Thresholds, Midwife/other agency to undertake Early Help Assessment and, if necessary, convene Team Around the Family meeting (TAF) in order to implement the Plan.

12-14 weeks If the criteria is met, in line with Thresholds, Multi Agency Referral Form sent to Multi Agency Safeguarding Hub (MASH). If following MASH checks it is deemed appropriate, a Children and Family Assessment begins. Assessment to be completed within 14 days (maximum). If the unborn baby has siblings who are already open to Children’s Social Care, the allocated social worker should refer the unborn to MASH as soon as viable (approximately 12-14 weeks) and a Unborn/Pre-Birth Assessment will commence.

16 weeks Referrals to specialist health services or specialist midwifery (if available) completed if mental health issues or substance misuse are identified. If required, a referral should be made to learning disability services or an advocacy service completed. If open to Children’s Social Care, a multi-agency meeting (CiN) will take place. For pregnancies that meet the criteria, the Safeguarding Assessment/Pre or Post Birth Assessment will be completed and presented to Stage 1 Panel in week 21 / 22 for cases open to CAFCASS Plus and week 21-24 for all other cases.

22-24 weeks Review TAF meeting takes place if Early Help services are being delivered. Decision whether Early Help offer remains appropriate or whether escalation is needed. If referral is received after 22 weeks then a strategy meeting will be held and s47 considered, if there are concerns that the unborn child is at risk of significant harm.OrPre-Birth Assessment is finalised. If Pre-Birth Assessment has identified that baby is likely to suffer significant harm Children’s Social Care initiates a Strategy Meeting to include consideration of whether an Initial Child Protection Conference ICPC) is needed (within 15 days).

24-28 weeks ICPC to take place by week 30 of gestation. Children’s Social Care to ensure that child is discussed at the Legal Planning Meeting - if legal proceedings are considered to be needed (not CAFCASS Plus).

30-36 weeks Child Protection Plan implemented, to include Safeguarding Birth Plan (Appendix 2)

36-40 weeks Baby born (term)

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Appendix 5Pre-birth Assessment and Post Birth Planning

GuidancePre-birth ‘Good Practice Steps’In a High Court judgment (Nottingham City Council v LW & Ors [2016] EWHC 11(Fam) (19 February 2016)) Keehan J set out five points of basic and fundamental good practice steps with respect to public law proceedings regarding pre-birth and newly born children and particularly where Children’s Services are aware at a relatively early stage of the pregnancy..

In respect of assessment, these were:

a risk assessment of the parent(s) should ‘commence immediately upon the social workers being made aware of the mother’s pregnancy’

any assessment should be completed at least 4 weeks before the mother’s expected delivery date

the assessment should be updated to take into account relevant events pre and post delivery where these events could affect an initial conclusion in respect of risk and care planning of the child

the assessment should be disclosed upon initial completion to the parents and, if instructed, to their solicitor to give them the opportunity to challenge the Care Plan and risk assessment.

Pre-birth guidance in Barnet considers that the earlier the assessment is undertaken the better the planning around the parents, extended family and the unborn child. This will include early referral to Family Group Conference, and where legal proceedings are considered, fostering to adopt. Therefore a referral at 12 weeks of pregnancy is considered to be good practice; child in need planning can commence with a view to convening an initial child protection conference from 30 weeks of the pregnancy.

Where there is significant parental history, including current and/or previous child protection concerns relating to other siblings, starting the assessment around 12 weeks of the pregnancy provides an opportunity to both work more closely with parents and to analyse and reflect on the information available.

At the point of starting the assessment, a multi-agency Child in Need meeting should be held within 3 weeks in order to plan the Pre-Birth Assessment. The views, information and support available from partner agencies should be sought and incorporated into the assessment.

Additionally, if the outcome suggests the baby would not be safe with the parents then practitioners are provided with the time and opportunity to make clear and structured plans for the baby’s future, and set up support for the parents where necessary.

The pre-birth assessment will:

focus on strengths and concerns about both parents and extended family members

assess the family history of both parents, the fathers of any previous children, and the extended family, previous proceedings and any previous expert reports/assessments including parenting assessments

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assess concerns about parental mental health, substance misuse or learning disabilities including previous involvement with mental health or substance misuse services

assess parents’ attitude to new baby and preparedness for its birth

build good relationships with the family, especially the expectant mother, using strength based approach, relationship based practice and motivational interviewing and gain an understanding the family systems

consider what support the expectant mother and partner will require and find avenues for this support

seek to engage support from wider family, and may consider Family Group Conference early in the assessment process where necessary, and identify the support needed for the family in order to safely parent the child.

There is a defined period for completion of the Children and Family Assessment,which is 45 days in total, with a review point at 20 days, it is expected that the majority of these assessments will conclude at 45 days in order for a full and thorough assessment to be completed. The aim is always to conclude, where possible, the pre-birth assessment to enable child in need planning to begin by around 27-30 weeks of the pregnancy. A birthing plan will need to be shared with the multi-agency professionals prior to the birth. The unborn baby’s father and mother’s current partner (if different) should be included in the assessment.

If the assessment does not indicate that the baby will be at risk of significant harm when born but may be a child in need, then the planning and provision of services will continue under s17 of the Children Act 1989.

If, however the assessment does indicate that the baby will be at risk of suffering significant harm then a Child Protection Conference will be held at 30 weeks gestation.

The Child Protection conference and any subsequent reviews will proceed as per all other conferences, the first review being held within 4 weeks of the baby’s birth or in exceptional circumstances within 3 months with the approval of the responsible Social Work team manager and Child Protection Reviewing Officer.

If the decision is made to proceed with a child protection plan for the unborn child, then the name ("Unborn" mother's name) and the due date of delivery should be entered on all electronic and hard copy records. The baby's record should be linked with the mother's record.

When the baby is born the midwife should inform the social worker.

The core group should meet before the birth, and also before the baby is discharged from hospital. The Core Group record should highlight the:

outcome of assessment

pre/post birth plans, including Child Protection Plan

managing non co-operation

removal at birth – if the plan is to remove the baby at birth, plans must be in place to fulfil the statutory requirements relating to Looked After Children and the preparation of foster carers if any post-birth health needs are likely.

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Legal Planning Meetings (LPMs) will be undertaken by Children’s Social Care (CSC) departments when necessary; the recommendations of LPMs will be shared with the Core Group and any other relevant partner agencies as appropriate.

Even when it is agreed that the Local Authority have decided to apply to the Family Court to seek removal of the child at birth, a Child Protection Conference should always be convened.

Multi-Agency Pre & Post Birth Plan A Multi-Agency Pre & Post Birth Plan must be created by 34 weeks gestation or as soon as appropriate once pregnancy is known. This is the responsibility of the Lead Professional (Social Worker if open to CSC) and should be made in agreement with their manager, the Safeguarding Midwife and any other relevant professional. The plan will include the arrangements for delivery and the immediate post-natal period. Where there are concerns about a family irrespective as to whether the unborn baby is subject to a child protection plan, a multi-agency pre & post birth plan should be agreed. The agreed plan must be kept where practitioners can access its contents in and out of hours to enable midwives and Social Workers to know how to respond. The plan should be shared with parents unless to do so is felt to put the mother or baby at increased risk.

The multi-agency pre and post birth plan should include contact numbers and names of professionals’ involved and clear directions as to where the infant should be cared for following delivery, depending on the risk. Where CSC have the lead professional role, it is the responsibility of the allocated social worker to ensure that CSC ‘Out of Hours’ are made aware of the multi-agency plan. It is the responsibility of the midwife agreeing the multi-agency pre and post birth plan to ensure that other health practitioners involved are informed, for example the obstetrician, neonatologist, GP, HVs, Family Nurse and the safeguarding team within the relevant health agency. All agencies should know what role they have at this time and be clear about their responsibilities.

Plans for discharge for babies identified by this protocol are usually made at the pre-birth planning meeting. Where this has not occurred, there are last minute changes to the plan or new or increasing concerns/risks have emerged, discharge plans should be discussed with CSC and or other involved agencies and a pre-discharge planning meeting arranged.

The plan should recognise that hospitals are not secure settings. As such the plan should consider contingency plans to include the period between birth and discharge from hospital. It should consider the role of the police in any immediate protection requirements. Where discharge is likely to be complex e.g. discharge to foster placement a pre-discharge planning meeting must be considered.

It must be recognised by all professionals involved that multi-agency pre and post birth plans can change at short notice and can be fluid. Professionals should exercise their professional judgement to keep the baby and others safe.

In situations where there is a delay in discharge of mother and baby due to social reasons, as opposed to medical requirements, this needs to be agreed on an individual basis. If a hospital extension is required for social reasons only, risk assessments need to consider the role of the midwife and the risks to the baby. The hospital can, in these situations, charge the Local Authority for the extended stay. It must be remembered however that midwifery units are not a place of safety and supervision may need to be put in place by CSC.

The pre-birth risk assessment may conclude that the baby would be at risk of significant harm if the infant remains in parent’s care following birth. In these circumstances CSC may plan to apply to the courts for an Order to remove the baby to a place of safety following birth. Due to legal reasons,

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applications to court cannot be made prior to birth. It is the responsibility of the attending professional (normally the midwife) to inform CSC and where appropriate, the police, when labour starts and when the baby is born. It is, however, the decision of the courts whether to grant an Order and alternative care and management of the baby will need to be agreed by all multi-agency partners if this is refused (in this situation a Pre-Discharge Planning Meeting should always be convened to ensure robust plans are in place to keep the infant safe). If CSC are applying to court for an Order, the court will require a number of days to list a court hearing. There will need to be a safety plan for the new born baby between the application being made and the date of the hearing. Police Protection arrangements may need to be considered as part of the safety arrangements and the police should routinely receive a copy of the multi-agency pre and post birth plan in these circumstances. If Police Powers of Protection are agreed these can last up to 72 hours, but this is not automatic and there should be agreement in place detailing how long this will be required for and recorded, as well as contingency plans in case police decide not to exercise their Powers of Police Protection.

Facilitating Removal of Baby from Parent’s Care There is currently no available guidance outlining organisational and professional roles or responsibilities when removing babies from parents care which might include how and when the removal takes place, by whom, the correct process of doing so and the support mechanisms needed to support mothers and practitioners afterwards.

Each case should be assessed on an individual basis and where possible, with involvement from the mother/parents; in particular to ascertain her wishes in how this baby will be removed. There should be clear communication between the social worker, the midwife in charge of the mother’s care and where possible the Mother, to identify in advance, an appropriate place and who will facilitate the separation of baby from parents. Ensuring at all times that the needs of the baby are prioritised the parents’ wishes should be taken into account.

Support for Parents Practitioners should understand that Mothers who have a baby placed in alternative care, experience reactions that are akin to the grief and loss experienced by mothers whose babies have died (Marsh, 2014). Maternity Services should consider in each individual case, following discussion with the Mother and Social Worker, whether the taking of mementoes such as handprints, footprints etc. would be appropriate. Practitioners should also consider whether copies of mementoes should also be provided for the baby’s life story work. The following support networks are available and should be offered if appropriate.

Woman’s Aid www.womensaid.org.uk 0808 2000247

After Adoption www.afteradoption.org.uk

0800 8402020

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http://www.afteradoption.org.uk/

http://www.womensaid.org.uk/


Family Lives http://www.familylives.org.uk/

0808 800 2222

CAFCASS https://www.cafcass.gov.uk/

0300 456 4000

National Association of Child Contact Centres http://www.naccc.org.uk/

Natural Parents Network http://www.n-p-n.co.uk/

NPN Helpline: 0845 4565031

Grandparents Association http://www.grandparentsplus.org.uk/

0300 033 7015

Family Rights Group http://www.frg.org.uk/

0808 801 0366

MATCH http://www.matchmothers.org/

British Association for Counselling & Psychotherapy http://www.bacp.co.uk/

Psychological SupportIAPT 0208 702 5309

www.lets-talk-iapt.nhs.uk

Crisis Team 0208 702 4040

Support for Professionals Professionals who provide care for mothers whose babies are removed at birth or shortly after require education and support to enable them to provide effective care to the families they work with and to enable them to maintain their emotional wellbeing whilst doing so.

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http://www.lets-talk-iapt.nhs.uk/

http://www.bacp.co.uk/

http://www.matchmothers.org/

http://www.frg.org.uk/

http://www.grandparentsplus.org.uk/

http://www.n-p-n.co.uk/

http://www.naccc.org.uk/

https://www.cafcass.gov.uk/

http://www.familylives.org.uk/


Safeguarding supervision has known benefits to staff and should be accessible to them. The receipt of regular, formal safeguarding supervision provides individuals with the opportunity to reflect on their feelings when engaging with child protection activities including the removal of babies at birth and has significant benefits to safeguarding practice and emotional wellbeing (Hall, 2007). It is therefore the expectation that all organisations have robust mechanisms in place to ensure that that supervision is available to staff members and is accessible.

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Appendix 6 Agenda Template for Discharge Planning Meeting

Agenda Discharge Planning Meeting

Name of Attendee Position Signature

Name of infant:

NHS number:

DOB:

Childs intended GP (If child residing with foster carer please leave blank and see appendix 1):

Mothers name:

DOB:

Hosp number:

NHS number:

Address:

Contact telephone number:

GP Surgery:

Partner’s details:

Partners contact number:

Additional services involved & contact details:

Situation

Delivery and postnatal details

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Relevant medical Hx for mother and baby

Relevant observations or anything of note

Background

Family social situation and Hx Child Protection Y/N

Any Children’s service plan

Assessment

Outcome of social work assessment/court?

Fit for discharge?

Any additional medical investigations on-going? And timescales

for completion.

Recommendations

Parental responsibility?

Where will mother & baby be going home to? If baby going to foster care see separate form ‘Infants Placed into Foster Care’

Actions to be taken and by whom/PN visits.

Are all appropriate services in place from child’s holistic needs?

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Appendix 7 Discharge Form for Infants Placed in Foster Care

Discharge Form - Infants Placed in Foster Care

Foster carer name(s):

Contact details:

Address infant will be discharged to:

Infants intended GP and address:

Visitation agreement for parents:

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Appendix 8 - Neonatal and Maternity Medical Report

Neonatal and Maternity Medical Report- to be completed by medical team

Patient Details Ward

Patient name:

D.O.B:

Hospital Number:

NHS number:

Antenatal History

Date of booking and gestation at booking:

Concerns known / raised in antenatal period:

Management during antenatal period: ( both medical and psychosocial factors such as professionals meetings, case conferences etc)

Birth Details

Gestation:

Mode of Delivery:

Place of delivery:

Condition at birth and resuscitation details:

Birth weight:

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Medical Details ( Please attach additional information as required ie: body map / Xray reports and refrain from using medical terminology

Medical issues:

Treatment required:

Significant investigation results:

Estimated date deemed ‘medically fit for discharge’:

Ongoing medical issues at discharge, if any:

Medical follow-up arranged:

Name / Designation of person completing form:

Signature: Date:

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Appendix 9 - Nursing Report

Nursing Report- to be completed by nursing team

Admission date Ward

People present with child at admission:

Clinical Care

Nursing care required:

Child’s daily routine, including feeding and breast-feeding:

Parents

Parents’ engagement with nursing advice and treatment:

Parents’ participation in treatment (e.g with NG feeding, withdrawal scoring):

Parents’ attendance on the ward and other visitors:

(It is not necessary to report every visit that has been logged, particularly if visiting patterns have been normal. Please note if parents are frequently away when expected to be in attendance, or are uncontactable.)

Parental interactions with the child:

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Observations of parental interactions with other children/each other/staff members:

Nursing follow-up arranged, if any

Other Comments

Name / Designation of person completing form

Signature: Date:

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