the overview report of the serious case review in respect ... · 4 2. decision to undertake a...
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The Overview Report of the
Serious Case Review
In respect of
Child C
This Report has been commissioned and prepared on behalf of Wigan Safeguarding
Children Board.
Wigan Safeguarding Children Board Chair:
Kath Nelson
Review Panel Chair:
Annie Dodd
Author:
Jane Leather MA. RN. RM. HV.
Published by WSCB – 3rd June 2015
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Index
1 Introduction 3
2 Decision to undertake SCR 4
3 Membership of the Panel 5
4 Methodology 7
5 Terms of Reference for the Review 15
6 Parallel Processes 19
7 Timescale for the Review 20
8 Child C’s Life
Treacher Collins Syndrome
21
24
9 The family Contribution to the Review 25
10 Overview of Agency Involvement with Child C 26
11 Critical Analysis 47
12 Individual Agency Reports and Recommendations 99
13 Conclusions and Recommendations 112
14 Bibliography 119
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1. Introduction
1.1 On 21st February 2013, a call was received by the ambulance service to a four
month old baby who was not breathing.
1.2 On arrival of the ambulance, the baby, Child C, was found to be in cardiac arrest
and resuscitation was commenced. The history was that the baby had a recent
chest infection. Dad had put the baby down to sleep at 9.30 am on her tummy in
her Moses basket and at 10.05am she was found blue and was unresponsive
when he tried to wake her.
1.3 Child C was pronounced dead at the hospital.
1.4 Child C was known to have a congenital condition likely to cause physical
disability, and at first it was thought that this condition had caused her death.
1.5 Both the child and family were unknown to Children’s Social Care Services. The
family were in receipt of universal health services and specialist hearing services,
having many contacts and appointments with staff and there had been no
concerns about the family.
1.6 There had been a previous presentation at accident and emergency in December
2012 when Child C had suffered a fractured skull following an injury thought at
the time to be accidental.
1.7 Subsequent post mortem examinations found a number of injuries believed to
be of non-accidental origin of differing ages. During the Care Proceedings, Each
parent denied responsibility and said that the other must be responsible.
1.8 The parents were subsequently arrested on suspicion of murder and child
neglect. They were placed on police bail whilst an investigation is took place. In
October 2014, the outcome of the police investigation was that the father of
Child C was tried in Court on several charges of injuring her. He was found not
guilty by the jury
1.9 The actual cause of death for Child C at the time of writing this report is
“Unascertained”. It may be that the true cause is never found.
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2. Decision to undertake a Serious Case Review
2.1 The case was initially discussed at a meeting of the Wigan Safeguarding Children
Board (WSCB) Critical Case group at a meeting on 5th March 2013.This group is
part of the Wigan WSCB local learning and improvement framework, which
regularly ensures that reviews of cases of a serious or concerning nature takes
place.
2.2 The group agreed that the case met the threshold in Chapter 8 of Working
Together 2010 and that Child C had died and abuse or neglect were known or
suspected to be a factor on the death.
2.3 The Wigan Critical Case Group subsequently recommended to the chair of the
Local Safeguarding Children Board (LSCB) on 5th March 2013 that the case should
become a Serious Case Review (SCR). The chair of the LSCB accepted that
recommendation on the same day.
2.4 Under the current statutory guidance, Regulation 5 of the Local Safeguarding
Children Boards Regulations 2006 requires LSCBs to undertake reviews of
serious cases. This Serious Case Review met the criteria in Regulation 5(1)(e) and
5(2).
2.5 The Department for Education were informed of the critical incident and the
decision to undertake a Serious Case Review on 12th April 2013.
2.6 NHS England was informed of the decision to undertake an SCR on 12th April
2013.
2.7 The WSCB appointed an Independent Chair and Independent Overview Report
Author who met with the chair of WSCB on10th April 2013 to be formally
commissioned to undertake the work.
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3. Membership of the Serious Case Review Panel
3.1 The Independent Chair of the Serious Case Review Panel was Annie Dodd. Ms
Dodd was previously employed as an Assistant Director with a local authority
children's social care service and has over 30 years’ experience as a qualified
Social Worker. Ms Dodd is self employed as a consultant. She has previously
chaired Serious Case Reviews for other Safeguarding Children Boards in the
North West and is currently engaged in chairing another SCR for WSCB, but has
no other connection with Wigan Safeguarding Children Board.
3.2 The Independent Overview Author is Jane Leather. Ms Leather qualified as a
General Nurse and Midwife. She has been qualified as a Health Visitor for 31
years, initially working for 20 years as a Health Visitor in a challenging inner city
area. Ms Leather was formerly Nurse Consultant and Designated Nurse for
Safeguarding Children before retiring in 2011. She has been involved in Serious
Case Reviews for over ten years including complex cross border cases. She was
awarded a distinction for her Liverpool University MA Children, Policy, Practice
and Law degree. She has also worked as a Mental Health Act Manager in High
Secure Services for over 10 years and now works in this role across all services
within a mental health trust. She is currently commissioned to undertake
another overview report for WSCB but has had no other previous connection
with services or the LSCB in Wigan.
3.3 Neither Ms Dodd nor Ms Leather have had any operational involvement with the
case of Child D.
3.4 In line with the statutory guidance, a dedicated SCR Panel for Child C was
formulated. The Panel comprised of the following people:
Independent SCR Chair
Detective Inspector Greater Manchester Police
Head of Children’s Services Bridgewater Community Healthcare NHS Trust
Head of Midwifery and Children’s Services Wrightington Wigan and Leigh
NHS Acute Foundation Trust
Designated Nurse Wigan / Assistant Director of Safeguarding Wigan
Designated Doctor for Wigan
Head of Service Specialist and Targeted Services Wigan Local Authority
Head of Service Early Intervention and Prevention
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3.5 Each meeting was attended by the Wigan LSCB Business Manager who gave a
wealth of support to the review process.
3.6 The work of the panel was efficiently supported by the LSCB Administration
Officer, without whom the panel members would have had difficulty.
3.7 A decision was made to take any necessary legal advice via the WSCB legal
services.
3.8 The Independent Chair of the Panel and the independent overview author were
in attendance at all of the meetings.
3.9 The Serious Case Review Panel met on 9 occasions, on the following dates:
11th April
29th April
16th May
6th June
24th July
15th August
21st August
10th September
15th October
The panel meetings have been between two and seven hours
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4. Methodology
4.1 Once the decision was made to undertake a Serious Case Review, a dedicated
Panel was established consisting of appropriate senior managers along with the
Independent Chair and Overview Author.
4.2 The decision on 5th March to commence the Serious Case Review for Child C
came just before the release of new statutory guidance for LSCBs. Working
Together to Safeguard Children 2013 came into force on 15th April 2013 and this
guidance allows LSCBs to use any learning model for SCRs consistent with the
principles within that guidance.
4.3 The Serious Case Review Panel gave due consideration to the model of Serious
Case Review to use. They subsequently took the decision to undertake the
review as a hybrid model in part in line with the guidance and requirements
within Working Together 2010, but as far as possible informed by the Systems
Review model when undertaking interviews with staff. In particular the
practitioners were encouraged to reflect on their decision making and actions in
the context of the circumstances and clinical presentations that they faced at
the time.
4.4 This approach was taken to facilitate the maximum learning from this review; in
order to gain full understanding of precisely who did what, and the significant
underlying reasons behind why actions and decisions had been made.
4.5 Before commencing the review, the Independent Chair of the Panel delivered a
presentation to the Individual Management Review (IMR) authors outlining
both the key principles of the SCR and IMR process, and the important
contribution of the work that they were about to do. The presentation was
undertaken because several of the IMR authors were without recent experience
in the SCR process.
4.6 The presentation emphasised the need for the review to be evidence based and
child focussed, with special attention on the depth of learning to be gained from
the case. The Systems approach (an adaptation from the Systems methodology)
was included.
4.7 The SCR Panel convened for Child C consisted of senior managers who, whilst
very experienced within their own field, had had little or no previous experience
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of the SCR process. This resulted in some degree of lack of clarity as to the role
of the Panel and the process itself, impacting on the timescales for the progress
of the work of the Panel and in some cases, causing difficulties in deadlines
being met. With hindsight, the Independent Chair of the Panel is now of the
opinion that she should also have included a briefing session for Panel members
as well.
4.8 The records for the family had been secured by senior managers in each of the
relevant services as soon as the case came to the attention of the Critical
Incident Panel. This was to protect the records from loss or tamper.
4.9 Each Agency undertook a Rapid Appraisal at the commencement of the review.
The purpose of this was to identify any immediate actions that needed to be
taken.
4.10 A detailed and accurate chronology of the involvement of each of the services
with the family was prepared from the records by the IMR authors. The
individual agency chronologies were subsequently combined into a single multi
agency chronology.
4.11 Members of the panel gave careful attention to suitably anonymising the
documents in order to afford the maximum privacy possible to Child C, her
family members, and the staff and professionals whose work came under
scrutiny in the review.
4.12 Each contributing agency undertook a review of the service provided to the
family. The reviews were undertaken within a culture of learning and
improvement across the partner organisations.
4.13 The Individual Management Reviews (IMRs) were undertaken by managers who
were independent of the case and were not immediate line managers of the
professionals and services involved.
4.14 The IMR for children’s social care was co-authored to ensure appropriate
independence when the panel discovered that the particular manager to
undertake the IMR was the line manager of the team manager involved in the
case. This occurred because the Panel took the decision to include the SUDC
process in the Review.
4.15 The Bridgewater Community Trust IMR author was replaced when leave
commitments meant she could not finish the review. The new author was
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therefore supported by a co-author in order to meet the strict timescales for the
review.
4.16 No panel members were involved in the writing of the IMRs. This was in order
for the Panel to maintain a focus which was objective and challenging in the
scrutiny of the reports and maintain an appropriate level of independence. The
Designated Doctor was not present at the Peer Review meeting which discussed
the attendance by Child C at hospital on 6th December.
4.17 The IMRs were undertaken with rigorous attention to the task in hand, and with
an open and critical attention to detail. The final reports reflected transparency
about the necessary issues for each agency, and demonstrated areas of learning
and improvement.
4.18 The reviews also sought to understand and analyse professional practice from
the viewpoint and circumstances occurring at the time of events rather than
with the benefit of hindsight.
4.19 There was excellent communication between the Senior Investigating Officer
and the Independent Chair of the Panel with regard to police interviews for staff.
4.20 All of the IMR reports were of a good standard initially, although there were
some difficulties for some authors in meeting the necessary deadlines. The panel
subjected the reports to exacting scrutiny and challenge, culminating in the
delivery of constructive feedback to the IMR authors. The reports and
recommendations were then redrafted and amended and re-submitted to the
panel.
4.21 The following agencies were asked to submit IMRs:
Wigan Children's Social Care.
Greater Manchester Police
Bridgewater Community Trust
Wrightington Wigan and Leigh NHS Acute Foundation Trust (WWL)
The Named Doctor for Safeguarding Children undertook a review for the
Clinical Commissioning Group of the GP services provided to the family
Specialist Sensory Education Team
An IMR was also submitted reviewing the SUDC process
4.22 The following agencies were asked to submit information to the review, but the
panel decided that an IMR was not required as the organisations had little
involvement which would contribute to the learning in the case:
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Alder Hey Children’s NHS Foundation Trust
Royal Manchester Children’s Hospital
North West Ambulance Service NHS Trust
NHS Direct
Bolton NHS regarding half sibling
Next Generation Nursery attended by sibling FGU.
National Deaf Children’s Society
Lancashire Teaching Hospitals NHS Foundation Trust
4.23 Information was received from all of the above agencies with the exception of
NHS Direct, who had no contact with the family.
4.24 Information also received which informed the work of the panel included:
The minutes of the LSCB Critical Incident meeting which initially
discussed the case.
Strategy meeting notes held on 5th March
Report submitted from the Police Incident Log for the consideration by
the Critical Incident Group.
Notes taken from a reflective discussion on the case between the Named
Nurse and one of the Consultant Paediatricians.
The skeletal survey report undertaken 25th February 2013.
The school nursing records for IG were retrieved and relevant details
were included in the IMR
CDOP form B
Letter from the clinical director for paediatrics to the medical director for
WWL dated 12th March 2013.
In addition, the Overview Author was given a copy of the WWL Internal
Audit Report 2012 – 2013 Safeguarding Children undertaken by NHS
Audit North West.
4.25 Information was requested from the Pathology Department, but this was not
available at the time of conducting the review.
4.26 The panel were informed of the following letters sent by the Designated Doctor
once the review commenced:
A letter to the Consultant Radiologist requesting a second opinion on the
CT scan findings.
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A letter to an ENT surgeon requesting what advice regarding sleeping
position would be made when an infant has Strider due to laryngo
tracheal malacia (noisy breathing as a result of weaker muscles in the
throat).
A letter to the SUDC doctor requesting information about the home visit
undertaken.
A face to face discussion with the SUDC lead.
4.27 The following agencies and services searched their records but had no contact
with or knowledge of the family:
NSPCC
Youth Offending Team
SSAFA
Brook Advisory Service
Clarification was obtained by the Police with regard to NU being in the
Army.
4.28 A Clinical Commissioning Group (CCG) Health Overview Report was completed
by the Designated Nurse and Doctor who were both members of the Panel. This
is consistent with the 2010 Working Together guidance SCR model whereby
Designated Professionals review and evaluate the practice of all health
professionals including GPs and health services providers commissioned in their
area.
4.29 This report focussed on how health organisations have interacted together and
greatly assisted the Panel.
4.30 Since the review began, new guidance issued with regard to the conduct of
Serious Case Reviews, has led to discussions occurring within NHS England which
were not concluding that a Health Overview Report was always necessary.
However, the SCR Panel had decided to undertake this review in accordance
with the 2010 Working Together Guidance and therefore a Health Overview
Report was included.
4.31 The Designated Nurse sought advice from NHS England about who should sign
off certain health IMRs (GP and SUDC). It was decided that the Reports would be
signed off by the Clinical Commissioning Group Chief Executive Officer.
4.32 Throughout the process, the Police representative on the SCR Panel ensured
that communication with the Crown Prosecution Service and investigating police
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officers was efficient and effective. In addition the Senior Investigating Officer
met with the chair of the panel.
4.33 Updates on the progress of the review were provided to The Department for
Education by The Head of Service Specialist and Targeted Services Wigan Council
and NHS England by the Designated Nurse.
4.34 The Designated Nurse completed a STEISS notification on 9th July 2013.
4.35 The LSCB Business manager informed the Coroner by letter of the Serious Case
Review on16th April 2013
4.36 In June, the police investigation was continuing and there was no decision made
about any prosecution. The Independent Chair of the Panel subsequently had a
discussion with the chair of the LSCB about the timing of a formal presentation
to the board.
4.37 On 12th June a letter was sent to the chair of the LSCB requesting an extension to
the review. The Senior Investigating Officer had indicated to the Chair of the
Panel that there were active lines of enquiry concerning both of the parents
which could be compromised if there were to be discussion with either of the
parents. It was a complex on-going Police enquiry which required the input of a
number of forensic experts. The letter explained that experience elsewhere
suggested that the family contribution to SCRs offers a powerful perspective
which is important to include. There are other family members also, who may be
witnesses at a trial, whose contributions the panel would wish to invite.
4.38 It was therefore agreed that the review was to go ahead in all other aspects
apart from the family contribution. Draft action plans would be put in place in
the meantime and be reported on so that the Safeguarding Board at the end of
September so that the Board had some assurance that issues were being
addressed. The review was to be finalised after any trial, which was provisionally
expected to be by May 2014. In December 2013 the WSCB received a
presentation by the Independent Overview Author about the key lessons from
the case.
4.39 Letters were sent by the Independent Chair of the Panel to each of the parents
and to the mother of the half sibling informing them at the commencement that
a review of the case was taking place, and that they would have the opportunity
to contribute to the review at a later date if they wished. Information was
included in the correspondence which described the review process and
purpose. In addition both parents were offered sincere condolences on their loss
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and given contact details of the chair of the panel should they have any
questions to ask.
4.40 A decision was made by the panel not to approach the family further until after
the police investigation had concluded so as not to compromise any possible
criminal proceedings. However, the panel made a commitment that any learning
from the case would not be delayed. The second draft of the Overview Report
was approved by the Panel on 15th October 2013. At this point the Overview
Report was put on hold until information from any legal proceedings and the
views of the family could be included. The multi-agency action plan arising from
the Overview Report was, however, progressed, so that no delay in
implementing the lessons from the case arose.
4.41 The Finding of Fact Hearing in relation to Child C’s sibling took place with a
judgement date of 6th December 2013. Permission was given for information
from this Hearing to be included in the Overview report. However, by the first
week in February 2014 there was still no decision by the Crown Prosecution
Service in Manchester about any criminal proceedings. This meant that just on a
year had passed since Child C’s death without any decision with regard to
criminal prosecution whatsoever. As a result, the completion of the Overview
Report and Serious Case Review were both delayed.
4.42 The Chair of the Panel asked the LSCB to prepare the parents before the
publication of this report and be sensitive to the impact both the report and any
media reporting will have upon them.
4.43 The Head of Service for Specialist and Targeted Services was able to advise the
panel that support was in place for both surviving children with regard to
bereavement support. It was not known whether this case would generate
media interest. The WSCB has a process for planning media involvement and
interest. This plan was developed as the SCR and criminal investigation
progressed.
4.44 Feedback and debriefing to staff was planned for before the publication of this
report. The WSCB also planned how the lessons arising from this case would be
cascaded across the borough within three months of the review completing.
4.45 Wigan is situated within the north west of England. It is ranked the 65th most
deprived local authority in England. The population includes 2.7% from an ethnic
background other than white British with 1.8% speaking a first language other
than English. The population is increasing, but at a slower rate than both
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England and the North West. The census reports show 72,012 under 18 year
olds and 18% of school children are eligible for free school meals (this rises to
39% in the most deprived areas). There are 129 maintained schools (3
academies) including 6 special schools, and 20 children’s centres. The largest
Young Offenders Institution (Hindley) in Europe is in Wigan. Infant mortality is in
line with the national average.
4.46 In May 2012 the Ofsted inspection found that the overall effectiveness of
safeguarding services in Wigan was Good, with Good capacity to improve. The
contribution of health agencies to keeping children and young people safe was
found to be Outstanding at this inspection. Wigan has not undertaken a Serious
Case Review since 2009, before commencing two SCRs in quick succession:
another case in 2013, and this one.
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5. Terms of Reference for the Review
5.1 The general terms of reference for a Serious Case Review are to:
Establish what lessons are to be learnt from the case about the way in
which local professionals and organisations 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 will change as a result
Improve intra and inter agency working and better safeguard and
promote the welfare of children.
5.2 In particular, this SCR should be focused on Child C and the safeguarding of her
welfare. However, where historical factors have relevance, they should be
included, with explanations as to their relevance to Child C.
5.3 The Key lines of Enquiry were:
1. Examine whether all agencies kept the Child C and her experiences at the
centre of their assessments of and interventions with the family.
2. Examine whether all agencies and professionals gave due and proper
consideration to all diversity issues, including ethnicity, religion, language,
disability, age, culture, social background and integration and the impact of
these upon agencies assessment and service delivery.
3. Examine whether information sharing and communication systems within
and between agencies were effective in safeguarding Child C.
4. Examine whether historical information was given appropriate emphasis
within assessments and interventions. This relates to mother’s and father's
histories (including any known offending history, any substance misuse or
mental health issues) and any factors affecting parenting capacity, extending
to other adults (in particular the maternal grandparents) where this is
relevant to the care of Child C.
This includes the history of Child C’s older half sibling and sibling, and in
particular any concerns raised, or which should have been raised, about
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their care or injuries to them.
Any relevant historical information prior to the timescale for the Review
should therefore be added to the chronology and summarised and included
in IMRs.
5. Examine whether any safeguarding and child protection issues, in relation to
any of the children, were identified and dealt with appropriately by agencies.
Consider whether agency responses were correct and timely and whether
safeguarding procedures were followed appropriately.
This should include any opportunities the agency/service had to observe
parenting ability and interactions between mother and father with Child C
(and sibling). This should also include any opportunities the agency/service
provided to mother and father to speak independently of one and other
about any concerns or worries they had prior to the birth of Child C.
Information should be included about what help was offered by agencies to
the family and whether there were any indicators that suggest CAF processes
could have supported multi-agency work.
6. Examine the assessments, decision making, planning and services offered to
Child C by organisations.
7. Examine the presentation of Child C at hospital on 6 December 2012 and the
appropriateness of the assessments and decision making which followed and
whether local policies, procedures and protocols were sufficiently robust and
were followed.
8. Examine the appropriateness of the assessments and decision making which
followed from the death of Child C on 21 February 2013 and whether those
policies, procedures and protocols were sufficiently robust and were
followed.
9. Consider whether agencies had the necessary resources and capacity.
Consider also whether professionals working with the family were suitably
skilled and adequately supervised and whether there is evidence of
management accountability and support. The effects of any organisational
change during the period under review should also be considered.
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10. Throughout the Review, consideration should be given to previous Serious
Case Reviews (by this Safeguarding Children Board or elsewhere) and any
other relevant reviews. Information should be included about what has
changed, in relation to organisation or practice, since the period under
review, which would have impacted on the care of Child C.
Glossary
Child C Subject
IG Mother of Child C
NU Father of all of the children
FGU Full sibling to Child C
OU Half sibling to Child C
FFG Maternal grandmother Child C
TBC Maternal great aunt Child C
LQ Mother of OU
List of Acronyms
WSCB Wigan Local Safeguarding Children Board
LSCB Local Safeguarding Children Board
SCR Serious Case Review
SCBs Safeguarding Children Boards
IMR Individual Management Reviews
SUDC Sudden Unexpected death in Childhood
CDOP Child Death Overview Panel
ENT Ear Nose and Throat
SSAFA Soldiers and Sailors and Airmen’s Families Association
SPR Specialist Registrar
DLA Disability Living Allowance
HST Hearing Support Teacher
CT Computerised Tomography
SUDI Sudden Unexpected Death in Infancy
LA Local Authority
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SSET Specialist Sensory Education Team
TCS Treacher Collins Syndrome
CAF Common Assessment Framework
NAI Non Accidental Injury
TOP Termination of Pregnancy
I-SAPP Integrated Safeguarding and Public Protection Team
SIO Senior Investigating Officer
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6. Parallel Processes
Alongside the SCR, the following parallel processes occurred:
A criminal investigation was on-going at the time – suspicion of murder
and child neglect. However, the actual charges which the Court Case
considered were that of inflicting injury.
FGU was accommodated under Section 20 of the Children Act 1989 and
placed with foster parents. An Interim Care Order was granted on 1st
March 2013
An external Radiologist was commissioned to undertake a review of the
CT scan from 6th December to give a second opinion of the reporting.
The missed skull fracture was reported as a Serious Untoward Incident
via the Datixweb electronic incident reporting system
The Independent Chair of the Panel ensured that liaison took place with the Police Lead
Investigating Officer throughout the review process.
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7. Timescale for the Review
7.1 The time period for the Review commenced from March 2008 following the
conception of OU. The Panel determined that the Review should include any
relevant information about OU and cover in detail the lifetime of FGU and Child
C.
7.2 A decision was made to extend the timeframe for the review to 7 days after
Child C’s death when concerns arose about how the SUDC policy had been
implemented.
7.3 Additional historical information has been included in relation to all family
members.
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8. Child C’s Life
8.1. The time of writing the majority this report, it had not been possible to interview
any family members so the information about the family circumstances and
background is rather limited. The report was finalised after the court case and
when it became apparent that family members did not wish to have their views
included in the report.
8.2. From the records and information available to the Panel, the following is known
about the family.
8.3. Neither parent had any serious involvement with the police. IG had been the
victim of an assault when she was aged 19 years and she was scratched by a
female in a nightclub. She also had two arrests for shop lifting aged 15 years
leading to a reprimand.
8.4. NU had been arrested once for a minor public order offence.
8.5. There are no recorded incidents on the police records of any domestic violence
between IG and NU. However there are four records of minor domestic incidents
in 2007 between IG and a previous partner, each of which were arguments, and
on three occasions occurred after IG had been drinking alcohol and became
aggressive.
8.6. The parents met in early 2010. Prior to living together as a couple, the
chronology shows that NU had a child in a previous relationship. He kept in
regular contact with this child whom he saw every other weekend, including
staying overnight contact with NU.
8.7. NU worked nights as a fork lift truck driver in a local food production factory
from 9pm to 6am Sunday to Thursday. On return from work at 6am, NU would
then take over the care of the children. He would hand over care to IG late
morning then go to sleep himself. He participated in the bedtime routine before
returning to work.
8.8. Early in 2006 NU had enlisted in the army but took a discharge after three
months, and did not see active service. There is then a gap in his records of a
couple of years when nothing is known about NU.
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8.9. Little is known about the employment history for IG. She did work for some time
in a nightclub and she believed that this experience caused her hearing to be
detrimentally affected. She also worked as a shop assistant.
8.10. Whatever the cause was, IG was diagnosed with sufficient hearing loss as to
need hearing aids in both ears when she was pregnant with FGU. This must have
caused communication difficulties for her as she chose not to accept the hearing
aids. Individuals who are hard of hearing suffer differently to those who are
clearly recognised as deaf. Being hard of hearing can cause the individual to miss
certain aspects of conversations resulting in a presentation to others that they
are of lower intelligence that they really are, indeed two separate agencies
involved with the family reported that they had concerns that IG had some
degree of learning disability.
8.11. IG was living at home with her parents when she became pregnant with FGU.
The records indicate some relationship difficulties with NU during the pregnancy
and after delivery she told the maternity staff that she was going home to live
with her parents and siblings as she had plenty of support. However, it would
appear from the records that the relationship between IG and NU had
recommenced and by April 2011 they had moved house and set up home
together.
8.12. When Child C was born she went home to live with her mother IG, her mother’s
boyfriend NU and her sister aged two years. NU was the father of both children.
The family lived together in a three bedroom mid terraced local authority house.
8.13. The property where the family lived is within a close micro community. IG
appeared to outsiders of the home to present as confident and outgoing, but the
GP records show a different presentation for IG, one of periods of depression.
8.14. The professionals who visited the home reported that the home was “organised,
nice, warm with appropriate toys, space for the children to play and interactive”.
8.15. When Child C was born, she had a sibling with the same inherited condition as
herself. This meant that the family had a lot of hospital attendances to get to.
This must have interfered with the ability to have a normal family life as they
were constantly working around a diary of appointments.
8.16. In December 2012, NU began sending a series of suggestive texts to LQ, who
responded to them. NU took care to ensure that these communications could
not be found out by IG by keeping an old mobile phone at work for the purposes
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of communicating with LQ. Although without any apparent proof of any infidelity
on the part of NU, IG subsequently became insecure in the relationship. For a
period of time NU would gravitate alternatively towards one partner when he
encountered difficulties with the other.
8.17. IG knew that NU had been bullied about his facial appearance in school. Whilst
nothing is recorded to confirm this, it must have been a concern for her that this
was what the future held first for first FGU and then Child C. It is a matter of
speculation as to whether or not a parent would be more distressed at having
daughters with facial abnormalities that sons as traditionally girls still tend to be
stereotyped according to their external beauty rather than their internal beauty.
24
Treacher Collins’ Syndrome
8.18. Treacher Collins' Syndrome is a genetic condition which occurs in a proximately
1: 50,000 live births. It is a disorder of craniofacial development. There is much
variation in the clinical presentation, to the extent that it is not uncommon for
some people to remain undiagnosed. Most have people with Treacher Collin’s
Syndrome have normal intelligence, although hearing loss can contribute to
developmental delay.
8.19. The presentation varies but commonly is as follows:
Jaw and chin - Often underdeveloped and/or misaligned
Cheek bones can be absent or malformed
Downward slanting of eyelids
Absent eyelashes in lower inner one third of eyelid
Ears can be absent, underdeveloped or malformed (Microtia).
Unusual hairlines
8.20. Hearing Loss varies greatly in severity but is usually conductive in nature. Those
born without any external ears may be able to hear with the use of bone
conduction hearing aids
8.21. There are some associated problems which may occur with Treacher Collin’s
Syndrome. The underdeveloped jaw along with small nasal passages can cause
breathing problems, especially at night, known as sleep apnoea. In minor cases
the person may breathe heavily or snore, in more extreme cases a tracheostomy
or other breathing equipment may be required to help the person breathe.
25
9. The Family Contribution to the Review
9.1 Once the decision by the jury in the Court Case was reached, letters were sent to
both parents and the maternal grandparents to ask if they wished to contribute to
the Serious Case Review. A response was received from the grandparents to say that
they would like to contribute to the review, but that they were faced with an
impending Coroner’s Inquest for Child C around December 2014 and therefore asked
for a further period of time. In January 2015, once the Inquest had been held and
Christmas had passed, the WSCB Business Manager again wrote out to the
grandparents, and even allowing for some delay for them to consider their decision
and response, no further communication was had from them.
9.2 NU gave interviews in the local press after the Court Case, in which he emphasised
his innocence but he did not respond to any request by WSCB to contribute to the
Serious Case Review.
26
10. Overview of Agency Involvement with Child C
10.1. The individual agencies completed a full separate chronology which is included
within their IMRs. The agency chronologies detailed the relevant contact
episodes that that the agency had had with or on behalf of the children and
parents. This was combined into a full composite chronology of events and this
section summarises from those documents the key information and account of
what happened.
Background Information
10.2. In 2007, the mother of Child C (IG) attended hospital with the symptoms of a
miscarriage. She requested a termination, but in any event this was not needed
and the pregnancy ended as a miscarriage. No other information is known about
why this pregnancy was not wanted. However, the police records show four calls
to domestic incidents (as a result of arguments) including IG with a previous
partner that year.
10.3. The health visiting records have identified that Child C’s father (NU) also had a
child to a previous partner (LQ) in September 2008. This half sibling to Child C is
referred to within this report as OU. The records indicate that NU had not had a
relationship with LQ since March 2009. However, it is documented in January
2010 that NU was having contact with OU every other weekend.
10.4. At a particular home visit in April 2011 LQ went on to have a conversation with
her health visitor regarding Treacher Collins Syndrome. LQ requested that
screening for the condition was offered to OU as NU had been found to have the
syndrome. The screening performed in May 2011 subsequently found that OU
did not have the syndrome.
10.5. During the time that LQ was with NU, an incident occurred on 25th November
2008 at 10.15 am resulting in OU attending hospital as a result of a referral from
a walk in centre. She was aged 10 weeks old at the time. OU was accompanied
by both LQ and NU and the history given to the hospital was of the baby falling
off the couch and hitting her head.
10.6. The account given was that LQ had placed the baby in the corner of the settee,
and sat up; she turned around to get something and heard a thud. She turned
back around and the child was lying on her back on the carpeted floor. OU then
27
began crying, and but settled with some attention. There was no loss of
consciousness, and no fits were observed.
10.7. LQ thought the baby had hit herself on the back part of her head. Since the
incident OU had been feeding, was alert, smiling and seemed well. NU had been
upstairs in bed at the time as he was working nights. The child was examined at
the hospital by staff middle grade Doctor 1, who found no sign of injuries.
10.8. At this point the “working diagnosis” was that the case needed to be
investigated. It was considered to be a possible Non Accidental Injury, as the
story was inconsistent with the baby's movement and expected developmental
abilities. The clinical examination and medical history revealed nothing
abnormal. OU was noted to have not started to crawl yet, and no bruises or
injuries were found.
10.9. The plan was to admit OU to the ward and undertake a check with social care.
When discussing with the parents the need for OU to be admitted NU became
quite agitated and said he did not want to leave his partner on her own on the
ward in case it was dark when they needed to leave. This caused LQ to
breakdown into tears.
10.10. Doctor 1 subsequently had a discussion with the Named Doctor for Child
Protection, who undertook a detailed examination of the child. They both
agreed that it was odd that the child had fallen, but as there were no child
protection issues, it was deemed to be a matter of educating the parents about
safety, and they decided that OU could go home medically fit.
10.11. There is no evidence that any information was shared with the Named Nurse for
Child Protection at the time, and no referral was ever made to social care, other
than an enquiry to see if the family were known to social care as part of the
initial decision making.
10.12. The hospital attendance was followed up by the health visitor and nothing else
of note occurred to OU.
28
Events leading up to the Serious Case Review
2010
10.13. In March 2010, IG presented in Accident and Emergency with a history of falling
and having incurred an injury to her left arm and wound to her left elbow. No
further information could be found about this injury. Two weeks later she
consulted her GP presenting as tearful, quite depressed and drinking alcohol to
excess. She had left her boyfriend, and had stress at work. The plan was for the
GP to review her in two weeks.
10.14. However, the next attendance at the GP surgery for IG was on 9th May 2010
when she presented as seven weeks pregnant with an unplanned pregnancy to a
new partner.
10.15. At the antenatal booking appointment four days later, the history which was
taken by the midwife states that IG had had anti-depressants for Post-Traumatic
Stress syndrome, but the notes recorded at the time did not go on to explain
why. It is recorded later at her first scan appointment that this was as a result of
an attack, but no further information is known in any of the records about who
or why this diagnosis was made. IG was given information at this latter
appointment on counselling, stress and anxiety.
10.16. In the health visitors’ Notification of Pregnancy form sent by the midwifery
services, it was stated that IG had predictive risk factors for post natal
depression because of;
a history of depression,
an unplanned pregnancy and that
She had relationship difficulties with her partner.
10.17. The following month in June IG was seen in the Ear Nose and Throat clinic
complaining of deafness mostly affecting her left ear. An audiogram showed that
IG had a moderate to severe sensory neural hearing loss in both of her ears. The
plan was that IG should have hearing aids for both ears, but she did not agree to
have them.
10.18. On 29th October IG was 31 weeks pregnant and told the midwife that she was
“feeling down”. The expected practice would have been to record the ensuing
discussion, but this did not happen.
29
10.19. The remainder of the pregnancy was largely uneventful apart from some minor
obstetric matters, until at 34 weeks IG was found to have symptoms of pre-
eclampsia and she was admitted to hospital.
10.20. On 24th November 2010 Child C’s older sibling (FGU) was born, somewhat
premature at 34 weeks gestation and was therefore admitted to the neonatal
unit. NU and the maternal grandmother FFG visited her in the afternoon.
Written on the birth notification facsimile in the health visiting record is “mum
and dad have fallen out.”
10.21. Whilst in the neonatal unit FGU was noted to have multiple physical
abnormalities of the face and head which later would be diagnosed as 'Treacher
Collins' syndrome.
10.22. On 12th December during a conversation with a staff nurse, IG said she was no
longer with NU, and had no contact with him at that time. IG was going to live at
home with her own parents and siblings, as she had plenty of support. FGU was
discharged home two days later.
10.23. The primary home visit by the health visiting service took place three days after
IG arrived home. IG was noted to smoke 10 cigarettes per day and to take
minimal alcohol. She was living with her parents and maternal aunt (TBC). It is
noted in the health visiting records of that visit that IG was not currently in a
relationship.
10.24. The local health visiting Caseload Dependency tool used in Wigan was
completed, resulting in the family being identified as a “Blue” family because;
FGU was “born with small cleft to soft palate and Treacher Collins
Syndrome
IG was a single mother with possible mild learning difficulties
(NB. A “Blue” family within the caseload dependency tool used means families
are assessed as requiring high levels of intervention from the Health Visiting
Team – a minimum of monthly face to face contact is required.)
10.25. Another routine visit from the health visitor occurred on 21st December. A
telephone call received from the health visitor liaison on 23rd December
reported that FGU was discharged from the neonatal unit but that some
concerns were identified and there may be a need for support on parenting
issues, although this observation was not clarified further.
30
10.26. The last visit for this pregnancy from the community midwife took place on 28th
December, although IG was not actually formally discharged from the service
according to the local midwifery protocol.
10.27. On 30th December the health visitor phoned IG to tell her the results of
metabolic screening and that a new health visitor had been allocated to the
family.
2011
10.28. On both 6th January and 14th January 2011 FGU attended audiology clinic. At the
first appointment IG told the staff she had concerns about her own hearing but
now worked in a nightclub, and that her hearing had been fine prior to this. IG is
also recorded as saying during this attendance that she was unsure if NU had
Treacher Collins Syndrome.
10.29. At the second appointment the staff offered to test IG’s hearing. This time IG
reported having had problems with her hearing since a young child and that her
hearing had deteriorated further when IG worked in a nightclub. IG was very
upset about having the hearing test done as she had had a hearing test when
she was four months pregnant and was very upset about the suggestion at the
time that she should have hearing aids.
10.30. On 20th January it was confirmed that FGU had a moderate hearing loss,
probably conductive in nature.
10.31. The Specialist Sensory Education Team Hearing Support Teacher commenced
visiting the family on 24th January. IG told the workers that she was hoping to
get her own house.
10.32. Two days later FGU was noted as having typical Treacher Collins Syndrome facial
features whilst attending the audiology clinic with IG and the mother of IG (FFG).
10.33. The audiology team were told that NU also had typical Treacher Collins
Syndrome features but had never been tested to confirm a diagnosis. The team
were also told that NU was bullied when he was young because of his facial
features. NU was no longer in a relationship with IG, although they were still in
contact. The team advised IG that NU should attend the forthcoming genetics
appointment along with OU.
31
10.34. FGU continued to attend regularly for audiology clinic appointments and to see
the Specialist Sensory Education team.
10.35. On 3rd February the health visitor received a telephone call from the Sure Start
Link Worker who had been unable to contact IG. The health visitor subsequently
telephoned IG but spoke to FFG who told her the family had moved to a new
address.
10.36. Throughout February, FGU attended a developmental review at the GP surgery
which was satisfactory and the well-baby clinic. During a home visit by the
health visitor on 24th February the Mood Assessment tool completed by IG
indicated no concern regarding her mental wellbeing.
10.37. On 7th March a letter from Doctor 2 Consultant Clinical Geneticist to Consultant
Paediatrician Doctor 3 stated “FGU is three half months old and came to see me
in clinic today with her Mother IG, Father NU and Maternal grandmother .There
is no doubt that FGU does have Treacher Collins syndrome and no doubt either
that her father NU is also affected despite the fact that a diagnosis has never
apparently been made in him. FGU is the first born to the couple who have now
separated….NU as far as he is aware, has no family history of Treacher Collins
syndrome and no history of hearing loss or hearing abnormalities. IG has three
healthy siblings and no relevant family history. FGU is awaiting bone conduction
hearing aids….I have explained that Treacher Collins syndrome has been
inherited from NU. NU would have a 1 in 2 chance for a further affected child in
any future child. IG was upset at the confirmation of this diagnosis. “
10.38. Between March 2011 and March 2012, FGU had an uneventful period with the
exception of 9th February when she attended hospital having choked on some
chocolate, but she suffered no adverse effects from this incident.
10.39. This year was a very busy one though, with regard to her many appointments
and attendances with the different health and hearing services involved with her
care. In addition to nine contacts with the audiology service, there were twenty
three entries in the records from the Specialist Sensory Education Services
Hearing Support Teacher (HST). Seven of these entries relate to the support
given to the family over a failed Disability Living Allowance (DLA) claim.
10.40. There were six attendances at the well-baby clinic, and the health visitor
received five letters updating the service on FGU’s progress.
32
10.41. The health visitor failed to get a reply to two attempted home visits during this
period, and to one telephone call, although a further four telephone calls to the
home were successful.
10.42. There were very few missed appointments by IG and FGU, and on every occasion
any missed appointments were for justifiable reasons, which is commendable
for the mother of a young child.
10.43. IG herself did not have such a good year though. She presented to the GP with
symptoms of depression in August but then had to be taken off her prescribed
anti-depressant in September when the medication caused abnormal bruising.
She became pregnant in October and was issued with a thirteen week sick note
but miscarried in November. It is not recorded if the pregnancy was planned, or
how IG felt about it.
2012
10.44. However, on 25th and 29th March respectively IG attended hospital and the
community midwife to book for pregnancy care. At the first appointment IG was
noted to be weepy and unsure of continuing with pregnancy. She informed the
midwife that she wanted an amniocentesis to see if this baby had Treacher
Collins syndrome as she now had issues with the baby's father.
10.45. The Notification of Pregnancy form which was received by the health visitor
from the midwifery service on 10th April contained information which was in
conflict with the information shared at the previous viable pregnancy in that it
stated that IG had no predictive factors of post natal depression.
10.46. On 13th April, IG was again signed off sick from work for 4 weeks by her GP
because of depression. There is no further detail recorded of this illness.
10.47. The Specialist Sensory Team Hearing Support Teacher (HST) undertook a home
visit on 18th April with new batteries for the hearing aids and discussed 2 year
old funding for FGU, advising IG to contact the nearest Sure Start centre. The
HST also discussed contacting the National Deaf Children’s Society Family
Support Officer for a home visit with regard to the Tribunal for the benefits claim
(DLA). FGU was also due to have an operation on her blocked tear ducts in the
near future.
33
10.48. Between 25th April and 17th May, the health visitor had three telephone contacts
with the family to arrange transport for an attendance at Hospital 2. This was
followed by a home visit on 17th May when FGU was seen to be walking unaided
and was very sociable. There was a good array of toys available in the home for
FGU. IG reported that FGU used 2-3 words and was wearing her hearing aids. A
referral was made for FGU to the Speech and Language Therapy service with the
areas of difficulty identified as her ability to use language and clarity of her
speech. A referral was also made to the Sure Start Link Worker for support to
access the local Children’s Centre.
10.49. On 18th May at 02.40 hours, IG attended accident and emergency with a history
of falling down four stairs that morning. IG was fifteen weeks pregnant at the
time.
10.50. The next significant event was the result of the twenty week specialised foetal
pregnancy scan on 19th June which detected an eighty per cent chance that the
baby would have Treacher Collins Syndrome. IG stated that she did not want any
further invasive tests done to confirm the diagnosis.
10.51. The July home visit by the health visitor was postponed for a month when she
arrived to find the family in the process of moving home. The health visitor did,
however, refer the family to the Transport for Sick Children Service for
assistance in getting to an appointment on 12th July.
10.52. The regular reviews by the audiology service continued and a stronger hearing
aid for FGU was issued on 23rd July.
10.53. On 25th July, a home visit took place by the speech and language therapist to
undertake an initial assessment of FGU’s speech. IG and NU were both present.
The observations noted in the records included that FGU was interacting well
with both IG and NU. FGU presented as a “sociable and curious child”. IG and NU
reported no difficulties with FGU’s newly fitted hearing aid. A discussion
occurred regarding pursuing 2 year funding for a nursery place for FGU and it
was reported that the Link Worker was due to visit the following day regarding
this. FGU was diagnosed with a language delay and a follow up visit was planned
for 22nd August. However, the speech therapist subsequently gained no reply at
this visit. A further appointment with the service was cancelled and it was
October before a joint visit with the Hearing Support Teacher (HST) took place.
There is no evidence that the speech therapist shared her initial assessment
findings from July with the health visitor.
34
10.54. Despite the difficulties the speech therapist had in following up her initial visit,
the Hearing Support Teacher continued to successfully and regularly visit the
family and see FGU in audiology clinic.
10.55. IG attended for all of her planned ante natal appointments and scans both at the
hospital and with the community midwives. There is nothing on the
documentation about her partner recorded during the pregnancy by the
midwives.
10.56. On 30th October 2012, Child C was born at Hospital 1 at the end of a normal term
of pregnancy. However, the examination of Child C, firstly by the neonatal
paediatricians and then by the consultant neonatologist on call that day Doctor
3, found her to have typical features of Treacher Collins Syndrome. Child C was
subsequently referred for follow up at Doctor 3’s clinic.
10.57. Both IG and Child C were discharged home on 1st November into the care of the
community midwife. The consultant paediatrician who spoke to both parents
with regards to the diagnosis of Treacher Collins Syndrome stated that the
parents were happy with the plan for follow up by Doctor 3 and Doctor 4, a
consultant paediatrician with an interest in cardiology. Referrals were
appropriately made to cardiology for an assessment of a heart murmur,
audiology (Child C had failed an initial hearing test), the craniofacial team and
for visual screening as the condition often includes visual impairment.
10.58. The health visitor received the notification of birth that day, although did not
document this on the chronology of significant events form in the records.
10.59. Two visits were undertaken by the community midwife, who advised about safe
sleeping for Child C. When the health visitor visited on 9th November, IG, NU and
FGU were all present. The new baby care pathway was completed. Child C was
feeding well on formula milk and she had regained her birth weight. A number
of standard leaflets were given at this contact including home and car safety,
immunisations, stop smoking service, positioning your baby, and depression
during and after pregnancy.
10.60. The standard Safe Sleep messages including sleep position, co-sleeping, room
temperature, smoking, use of drugs and alcohol were discussed. Standard advice
was given to warn about ‘prop’ feeding.
10.61. The rooms observed during the visit were the hall and the lounge. No concerns
were documented regarding the condition of the rooms.
35
10.62. It is documented that IG smoked and had no current health concerns. Her
mental and emotional health were discussed, the Mood Assessment tool was
completed with IG which indicated no concerns. IG reported that she had
support from her partner, family and friends. The screening for domestic abuse
was not discussed with IG as NU was present.
10.63. A family profile was completed by the health visitor. The Health Visiting
Caseload Dependency Tool was completed. This time the family were identified
as “Level 1 – Universal Criteria – as per Healthy Child Programme.”
10.64. The next visit by the community midwife was on 14th November when Child C
was 16 days old. IG stated that she was tired and had a headache but that she
was happy to be discharged that day. Child C was feeding well every four hours
and was pink and warm.
10.65. On 15th November Child C was seen by the Audiology Service, accompanied by
IG, NU and FGU. Some concern was reported about her hearing. Child C had
initially appeared to startle to some sounds but IG and NU felt that this had now
stopped. An attempt was made to undertake the diagnostic auditory brainstem
response testing, but Child C was unsettled. It was decided to review her again
on 23rd November.
10.66. The same day the Hearing Support Teacher saw FGU because her hearing aid
needed a new cover.
10.67. On 16th November the health visitor received four letters copied to the service
concerning referrals for Child C to ENT, a cranio facial team, ophthalmology and
paediatric services at three different hospitals in the North West.
10.68. Child C was seen by the Audiology Service as planned on 23rd November. She
was accompanied by IG, NU and FGU. The parents’ concerns continued about
Child C’s hearing loss. Another attempt was made to undertake diagnostic
auditory brainstem response but Child C was too unsettled. It was agreed that
sedated auditory brainstem response was needed to verify these results.
10.69. The Hearing Support Teacher took advantage of seeing FGU whilst Child C was
being tested. FGU had now obtained her 2 year funding and was due to start
nursery after Christmas.
10.70. On 27th November Child C was seen by Doctor 3 in clinic. Her general
examination was unremarkable. She was noted to have a history of lactose
36
intolerance and colicky pain. Doctor 3 arranged to see the family in 4 months’
time.
10.71. On 2nd December at 04.44 hours NU was attended to by the ambulance service.
He had fallen six steps downstairs and slid on his bottom. Upon examination by
the ambulance crew NU refused to respond, he forced his eyes shut and would
not tolerate an airway. No obvious injury or deformities were found. Due to the
mechanism of the injury NU was secured onto the scoop stretcher with the use
of head blocks and straps, a cervical collar was also fitted. NU was transported
to hospital.
10.72. Child C was seen by the GP for infantile colic and snuffles on 4th December.
Again her examination was unremarkable.
Events on 6th December
10.73. On 6th December 2012 at 11.22 hours Child C was assessed by a staff nurse, at
Hospital 1. Child C had been brought into Accident and Emergency with the
following history. “Dad was changing her nappy and her sister hit Child C on the
head with a toy”. Child C had suffered no loss of consciousness, no vomiting and
she had a boggy swelling on left side of head. Child C was unsettled and crying at
the assessment.
10.74. The Accident and Emergency Registrar Doctor 5 was asked to see and assess
Child C. It was standard practice for the Accident and Emergency doctor to see a
child prior to being referred to a Paediatrician Registrar.
10.75. Doctor 5 examined Child C at 11.50 hours. He recorded that “Child C was on the
changing mat; her sister hit her on left hand side of the head with a toy about 45
minutes ago”. Child C had cried straight away and had cried intermittently since
then. Child C had taken a feed, and had no vomiting. On arrival her Glasgow
Coma Score was 15, a large boggy swelling was present in the left posterior
parietal region of her head, her pupils were equal and reacting to light, she had
no ear or nasal discharge or bleeding. She had good colour, her fontanel was
normal, she was moving her head and all her limbs were active. A CT brain scan
was requested.
10.76. The CT of Child C’s head occurred at 12.33 hours. The findings were as follows:
No acute intracranial haemorrhage.
37
A large subcutaneous haematoma over the left parietal occipital region.
On the reformatted images there is evidence of a non-displaced fracture
through the left parietal bone extending into the Coronal and Lambdoid
sutures.
No sutural distraction
10.77. In layman’s terms, the CT scan report showed no bleeding inside the skull, a
large visible lump on the left side and running towards the back of her head
caused by a blood clot, one fracture to the skull in the same area but the bone
was not put out of place at all. The history taken by Doctor 1 was “Child C was on
a foot stool, NU was changing her nappy, her older sister was playing beside
them on a chair. She fell from the chair and landed on Child C”
10.78. The paediatrician Doctor 1 said at interview that he did not look at CT scan itself
as it is normal practice to accept the report from experts.
10.79. At some point during 6th December, but the time was not recorded, Doctor 1
clarified the history of the injury from NU. NU said “Child C’s older sister was in
chair with a toy in her hand when she fell over Child C”. The doctor recorded “So
the history fits with accidental injury as there is no other injury noted, to contact
social care if there are any concerns”.
10.80. At 14.40 Doctor 6 documented the CT scan findings. Doctor 6 also documented
that Paediatric Registrar Doctor 7 advised a plan to observe Child C overnight,
and that no further action was needed at present. NU was told of the plan and
he had no questions. Doctor 6 noted that history documented by the Accident
and Emergency Doctor stated “that Child C was hit over the head with a toy by
her older sister and that the history documented by the paediatric doctor states
older sister fell off a chair onto Child C” . Doctor 6 noted in the records an
intention to discuss the case with her seniors regarding the inconsistent story of
the injury.
10.81. Child C was subsequently seen by the paediatric registrar Doctor 1, and the
decision was confirmed to admit her for observation. The nurses recorded that
NU was resident on the ward and attending to all of Child C’s care.
10.82. Child C remained stable and at 11.30am the following morning at the ward
round on 7th December, NU was told that the plan was to probably discharge
Child C later that day.
10.83. Doctor 1 did not see Child C on the ward round that morning, as Child C was in
eye clinic at the time of the ward round having an assessment. Doctor 1 was
38
covering for the “Hot Week” Consultant ward round and he did not have a
Registrar for support.
10.84. (N.B. The “Hot Week” system is part of a national initiative supported by the
Royal College of Paediatrics and Child Health to increase the number of
consultant paediatricians present in hospitals over a twenty four hour period, as
having consultant led care is a matter of good practice, with the aim of having
better continuity of care. Within this particular hospital trust, the system had
been expanded outside of the consultant quota. The introduction of middle grade
doctors into the “Hot Week” rota was introduced following a vacancy which
occurred within the team of consultant paediatricians and the consequent gap in
the consultant on call rota. It was decided by the paediatric consultants that
senior middle grade registrars could act up into a consultant role as a training
opportunity in the “Hot Week”.)
10.85. At 13.50 the nursing notes record that the parents were waiting for a doctor to
speak to them so that they could take Child C home.
10.86. At 1500 hours Doctor 1 discussed the case with Doctor 8, consultant
paediatrician. Doctor 8 had been the Named Doctor for child protection but on
the 7th December he had already relinquished his responsibilities of this role to
another consultant. Doctor 8 advised Doctor 1 to contact social care and the
health visitor to see if there were any concerns with the family. Doctor 8 also
advised Doctor 1 to consider a skeletal survey if there were any concerns.
10.87. Doctor 1 subsequently spoke to the Duty Social worker. The family were not
known to social services and the address was also not known to them. He did
not, however, undertake a more detailed assessment using the child protection
medical proforma because he said he had limited time and limited support.
10.88. Again on 7th December but the time is not noted, it is recorded that Doctor 1
discussed the case at the Xray meeting. The records of the meeting state “no
intercranial haemorrhage, fracture to the left parietal occipital area, it could be
accidental, Doctor 3 knows the family and has no concerns”.
10.89. At 1600 hours Doctor 8 spoke with a health visitor. The health visitor had
inspected the records and found no items of concern, no missed visits, no
domestic violence history.
10.90. The health visiting records concur with this story stating that Doctor 8 spoke to
the health visitor regarding Child C sustaining a fractured skull. The incident
apparently occurred “when Child C was lay on a changing mat and FGU hit Child
39
C on the head with a toy telephone”. Doctor 8 told the health visitor that he had
already contacted children’s social care who had “no history” of the family.
10.91. Doctor 8 had also retaken the history of how the injury occurred; “NU stated he
had put Child C on a changing mat which was lying on a raised stool at 10.30 am
yesterday. Her sister was sitting on a chair next to the mat playing with a large
plastic toy phone (old fashioned shape) she lost her balance and fell forward with
the toy in front of her and landed with it onto Child C’s head”. Child C cried and
NU felt where the toy had hit her and felt that a bump was developing. He got
Child C’s mother who was upstairs and they rang the Paediatric Service 1 for
advice as Grandma had told parents to put butter on the swelling. They were
told to come straight up and arrived within 30 minutes of the injury occurring.
Doctor 8 recorded that the parents both understood why the doctors have to
ask the questions over what happened and they wanted to be as honest as
possible about what happened.
10.92. Doctor 8 was happy to believe the story having gone over it with the parents.
The records state “feel we don't have any grounds to suspect this is a non-
accidental injury”. A diagnosis was therefore made of an accidental injury and
Child C was sent home with home safety advice and information regarding head
injury monitoring at home.
10.93. No skeletal survey was undertaken. Child C was 5 weeks old at the time of this
injury.
The Peer Review Meeting
10.94. On 10th December 2012 the Monday child protection peer review meeting took
place. Child C’s attendance at hospital was discussed. The notes of the meeting
record: “Child C was a known patient with Treacher Collins syndrome under the
care of Doctor 3. NU reported he had been changing Child C’s nappy on the
changing mat which was on a small foot stool whilst IG was having a lie in. His
elder daughter was standing on a small chair next to them and was holding a
hard plastic toy phone. The older sister then fell off the chair and had fallen onto
Child C and hit her on the head with the plastic toy phone. NU felt a bump come
up immediately on Child C’s head. He telephoned Paediatric Emergency Care
Centre who suggested bringing C to accident and emergency and they arrived at
11.00 am.
40
10.95. Child C was seen in accident and emergency by registrar Doctor 1 and he found a
swelling in the left posterior parietal area. A skull x ray was not performed but a
CT scan of the skull was carried out which revealed a skull fracture. This was
undisplaced. Child C was admitted to the ward for observation.
10.96. Doctor 1 was concerned about the story given and asked Consultant Doctor 8 for
his opinion. Doctor 8 suggested that Doctor 1 contacted social care and the
health visitor for further information. No concerns were expressed by social care
or the health visitor. Parents are good clinic attenders. Doctor 8 took the history
again from the parents. Doctor 8 felt the story was consistent with the injury.
Outcome: Child C was allowed to go home with parents Doctor 3 will follow Child
C up in his clinic as previously arranged”.
10.97. The case generated a lengthy discussion regarding the outcome; however the
minutes of the Peer Review meeting do not fully reflect this discussion, and the
chronology had to rely on the accounts at interview for some pertinent detail.
10.98. There was an active discussion involving most of the Consultants. Doctor 3 who
was Child C’s consultant for her Treacher Collins Syndrome had also treated
Child C’s older sibling and felt that the family were “of very good repute and
were very nice”.
10.99. The explanation given from the family was “that an older child was standing on a
cushion slightly above Child C holding a metal toy telephone in the air. The older
child fell over and the toy telephone hit Child C on the side of the head”. This was
accepted as a reasonable explanation for the injury, which was then classed as
an accident.
10.100. Discussion took place regarding whether a skeletal survey should have been
performed in view of the injury and age of the child, this opinion was supported
by two of the six consultants present. The meeting also considered safeguarding
concerns. A third consultant stated at interview that he initially thought the case
was one of non-accidental injury, however “due to additional information
discussed, he changed his view.”
2012 continued
10.101. On 11th December Child C was admitted as a day case for sedated auditory
brainstem response. IG and NU reported that Child C sustained a fractured skull
on the left side above mastoid area the previous week “when FGU hit her round
the head with a stool”.
41
10.102. IG and NU reported that the doctors apparently told them that the fracture
would not affect Child C’s hearing. Child C still had a large swelling on the left
side of her head. She was settled throughout testing until staff placed the bone
conductor on, and then Child C became distressed, limiting the testing. The test
results showed that a bone anchored hearing aid would be the most appropriate
treatment. NU was the main caregiver whilst Child C was on the ward for this
admission, although IG was present, she sat and observed.
10.103. The same day of the hearing tests, a health visitor telephoned IG following the
head injury attendance at Hospital 1. IG reported that Child C was well and that
the swelling had gone down. No concerns were expressed by IG to the health
visitor, who invited IG to contact her as required. The health visitor recorded
that she planned to see the family on the second of January at home for a 4 to 8
week contact.
10.104. On 20th December Child C attended the GP for the routine 6-8 week child health
surveillance. It is documented that the examination of cardiovascular and
respiratory systems were normal at this time.
10.105. The planned home visit by the health visitor on 2nd January was subsequently
rearranged to 30th January in a telephone conversation the same day with IG
and NU as a result of IG forgetting about the appointment.
2013
10.106. The family did not attend Hospital 3 with Child C for an appointment on 7th
January and a new appointment was sent out to them.
10.107. Child C did however attend for her first immunisations at the GP practice on 8th
January and the Specialist Sensory Education Team visited Child C on 10th
January.
10.108. At a clinic appointment with the cardiologist on 17th January, Child C was found
to have a quite marked upper airway noise which was worse when she was lying
on her back. The advice given was for Child C to sleep on her side.
10.109. At the arranged home visit by the health visitor for the 3 to 4 month contact on
30th January, the health visitor Care Pathway was completed and Child C was
then thirteen weeks old. Child development was discussed. A supply of suitable
toys was seen to be available, and a clean and safe area of floor space available
42
for play. Social skills, feeding/nutrition and dental health were also discussed,
along with bedtime routine and the reinforcement of the safe sleep messages
and home safety.
10.110. Child C was reported to sleep through at night. IG was advised regarding
smoking. The Mood Assessment Tool was completed. There was no suggestion
that IG was low in mood. The screening for domestic abuse was not completed
due to NU being present. The plan recorded was to refer to Transport for Sick
Children Service and for a health visitor to see Child C again at the 9 to 12 month
contact, or sooner if necessary.
10.111. On 4th February, Child C was seen by the GP with a cough and reduced feeding.
The GP diagnosed a viral upper respiratory tract infection with wheeze. FGU was
also seen by the GP with a complaint of a cough for the last 3 weeks. A chest
infection was diagnosed and antibiotics were prescribed for FGU.
10.112. Child C did not attend the GP surgery the following day for her scheduled second
immunisations and a letter was also received by the GP stating that she had
been discharged from the ENT clinic as a result of missing two appointments.
10.113. On 5th February IG did attend Hospital 4 because of an unplanned pregnancy.
The records state “Father unaware”. IG gave a history of two miscarriages and
two live births. She requested a medical termination for an unplanned
pregnancy; marital status - has a regular partner.
10.114. FGU did not attend an appointment at Hospital 2 on 6th February. An email was
received by the health visitor from the Transport for Sick Children Service. The
email indicates a “wasted trip” for the service on 6th February. It stated “the man
who answered the door said he was looking after the children and that mum had
been out all night. The man also said he knew nothing about an appointment”.
The Transport for Sick Children Service also noted that the mobile number that
they had for IG was never answered.
10.115. The following day, the health visitor tried to telephone IG regarding the email
from the Transport for Sick Children Service however no reply was obtained. A
voicemail was left requesting IG contact the health visitor.
10.116. Child C was taken to the GP on 8th February when she had not improved and was
prescribed antibiotics. She was accompanied by IG and NU. Both parents came
across as caring and asked pertinent questions regarding Child C’s health and
presenting condition. Child C was undressed and examined by the GP. In light of
43
the parental concern, the GP telephoned the parents later that day at 1800
hours and was told that Child C had fed well and had improved.
10.117. A home visit from the Hearing Support Teacher also took place on 8th February.
IG attended for her medical termination of pregnancy on 11th and 12th February.
10.118. Telephone conversations took place on 13th and 20th February between the
parents and the audiology administrator and the speech and language therapist
respectively.
Events From 21st February
10.119. At 10.18 hours on 21st February, a call was made from the Ambulance Service to
the Police Service reporting of an ambulance attendance to Address A for a 4
month old child who had stopped breathing, and was being taken to hospital.
This child was Child C.
10.120. Child C had been restless during the night and had been fed by IG. NU said that
he had returned home at about 06.05 am from working nights. On his return he
went upstairs and collected Child C from her cot and took her downstairs. He
played with her in her baby swing until she became restless at about 8am so he
placed her in her Moses basket. He said that due to her condition they had been
told to place Child C face down when sleeping and he did this with her face to
the side. He did not feed Child C and IG and FGU remained upstairs asleep. He
stayed in the living room watching TV and having his breakfast until at
approximately 9.45am he discovered Child C face down and fully into the
mattress of her Moses basket. He picked her up and saw that her face was blue
and alerted IG. IG concurred with this account. IG rang the ambulance service
who gave both parents instructions on how to perform resuscitation until the
ambulance arrived and staff took over.
10.121. The time of Child C’s death was recorded as 10.40 hours by Doctor 3 The police
and SUDI team were informed. The history given to Doctor 3 was that
NU had been awake until 09.30am as he had been working on nights and he had
put Child C in the Moses basket (on her belly) he watched TV for a while and
then he attended to the older child who woke up. He found Child C in her Moses
basket face down completely covered. He was unable to wake her.
10.122. The account recorded by the ambulance service was that the mother stated she
had found baby face down and that her face had gone blue.
44
10.123. Police Officer 1 took charge of the police investigation. He was introduced to
Doctor 3 who informed him that Child C and other family members were all
affected by a genetic disability (Treacher Collins Syndrome) which caused facial
deformity and potential respiratory problems. Police Officer 1 learned that Child
C had presented at hospital two weeks previously with respiratory problems and
had been prescribed antibiotics. Also that the child had been diagnosed with a
fractured skull in December 2012 but that Doctor 8 who had examined Child C
did not consider this a case of non-accidental injury. Doctor 3 told Police Officer
1 that he had never had cause to raise any safeguarding concerns in respect of
Child C or the immediate family.
10.124. Police Officer 1 was made aware of the result of the checks with Children’s
Social Care and Police systems. Neither agency had any records indicating any
cause for concern in respect of safeguarding considerations around the family. In
addition officers at Address A reported no obvious cause for concern identified
at the family address. Both parents appeared very distressed.
10.125. Police Officer 1 remained present whilst Doctor 9, the SUDI paediatrician,
obtained a history from both parents and conducted a physical examination of
Child C. There was a small bruise on the left of her forehead but this did not
appear overly significant at the time. There was nothing immediately apparent
found on the examination which indicated that the baby had suffered any kind
of injury or trauma which would have caused the death.
10.126. The social care child in need team received information from the police at 12.00
hours and 13.30 hours that day. System checks identified that the family was not
known to the department. No concerns were raised in respect of cause of
death. No action was taken.
10.127. At around 1500 hours (the exact time of the visit was not recorded) Doctor 9 and
Police Officer 1 conducted a joint visit to Address A. Police Officer 1 recorded
that although untidy there was nothing to indicate any concerns at the address
in relation to safeguarding considerations. A joint decision was taken on the
basis that there were no apparent suspicious circumstances at this stage. The
decision was that a forensic post mortem was not required.
10.128. A telephone call at 9 am on 22nd February informed the health visitor of the
death of Child C.
10.129. On the 25th February, four days after the death of Child C, a skeletal survey was
conducted at Hospital 3 and at the same time Doctor 10 reviewed the earlier
45
scan from 6th December 2012. She found another older skull fracture and
identified several further fractures to the ribs of different ages. The Coroner was
updated and a Home Office Post Mortem was agreed.
10.130. At some point that day, the health visitor received a telephone call from Doctor
9 who wanted to confirm if advice had been given by the health visiting Service
to place Child C in the prone position to sleep. The health visitor told Doctor 9
that no advice to place Child C to sleep in the prone position had been given by
the health visiting service, and that the standard safe sleep advice had been
given to parents.
10.131. Doctor 9 told the health visitor that NU had stated that a health professional had
advised that Child C should be placed in the prone position for sleep. Doctor 9
said that there is some research to support advice to place babies with Treacher
Collins Syndrome in the prone position due to risk of swallowing the tongue if
they lay on the back.
10.132. At 18.25 hours a discussion took place between Police Officer 2 and Police
Officer 1 regarding the potential safeguarding issues relating to Child FGU as a
consequence of the skeletal injuries discovered on the body of Child C. A
decision was taken that there would be no immediate police action to remove
Child FGU from the care of the parents until such time as the results of the
forensic post mortem were known. Provisional arrangements were made by
Police Officer 2 for forensic pathologist Doctor 11 to conduct a forensic post
mortem at 10.00am on Wednesday 27th February 2013 at Hospital 3. The
Coroner was informed.
10.133. On 26th February, five days after the death of Child C, at 15.15 hours, a referral
of circumstances was made to children’s social care with a view to convening a
safeguarding meeting in respect of Child FGU. The initial safeguarding plan
proposed by police was outlined to social care. Agreement was made for a joint
visit to the home by police and social care and the social care Service Manager
was updated by the team manager.
10.134. At 19.30 hours, the planned home visit was undertaken. There was discussion
with the parents of Child C and FGU regarding the concerns raised in respect of
their daughter and the plans for a further Home Office Post Mortem. Both
parents were advised that due to the identified concerns, a safeguarding plan
was required. FFG was in the property at the time of the visit and agreed to
supervise all contact between FGU and her parents until further notice. All
parties signed a working agreement to this effect.
46
10.135. On 27th February, the Home Office post mortem was conducted by Doctor 11
and Doctor 12 together with a geneticist specialising in congenital syndromes.
The following injuries which were deemed as non-accidental were found at the
examination which included:
Fractured left side of the skull (consistent with injury reported on 6th
December 2012)
Fractured right side of skull (appears to pre-date 6th December )
Depressed fracture of the skull with bruise
A variety of rib fractures, multiple on both sides some with bruising (from
two to three different occasions)
10.136. The cause of death was unascertained.
10.137. Doctor 9 rang Social Care Team Manager 1 to tell her that the post mortem had
commenced and was part way through. In an update provided by Doctor 9 in
respect of injuries identified, he reported that there were approximately 9 rib
fractures of different ages, 2 skull fractures and in addition, bruising to the body
of Child C had also been identified. The Head of Service and key safeguarding
leads were informed by the Service Manager.
10.138. As a consequence of the post mortem examination findings the police
investigation was re-classified as a homicide investigation and a designated
Senior Investigating Officer was appointed and briefed.
10.139. At 16.30 hours, a Strategy Meeting was held at Police Station 1 involving: Doctor
9, Police Officer 3, Social Care Team Manager2, Social Care Team Manager 1 and
Social Worker 1. Doctor 9 confirmed the findings within the post mortem and
advised that the injuries sustained were considered to be non-accidental in
nature. In addition to the above identified injuries Doctor 9 advised that there
was a possible third skull fracture however this had not yet been confirmed.
Due to the identified concerns it was agreed that FGU would be placed in Local
Authority foster care whilst further enquiries were undertaken.
10.140. At 1900 hours a home visit was undertaken jointly with the police and social
care. Both NU and IG were arrested and FGU was made subject of a Police
Protection Order and placed with LA foster carers.
47
11. Critical Analysis
11.1. The analysis in this section is as a result of the information included within the
Individual Management Reviews, the discussions within the Panel meetings and
the author’s own contributions and research.
11.2. The analysis has been undertaken with the overt benefit and privilege of
hindsight, which was not available at the time to the practitioners involved in the
case. The detail within the reports submitted to the Panel will not be replicated
in full within this section. Rather the analysis will seek to identify any gaps in
individual agency learning, missed opportunities, weaknesses or failing in
practice, procedures and systems, as well as what worked well.
11.3. The initial guidance given to IMR authors, and the subject of Panel discussions
was centred on trying to determine why actions and decisions were taken or
omitted in order to provide the maximum depth of learning from the case. This
was to ensure that the relevant systems failures could be addressed thus
preventing any similar circumstances arising in the future.
11.4. The case of Child C is a rather unusual one for a Serious Case Review in that there
were never any concerns whatsoever expressed by agencies with regard to the
recognition of any risk or vulnerability within the family, despite a particularly
high number of professional contacts with the family. Working Together 2010
(the guidance in force at the time) states in 2.82:
“All professionals delivering Universal Services have key roles to play both in the
identification of children who may have been abused or neglected and those who
are likely to be; and in subsequent intervention and protection from harm.”
11.5. Universal Services are offered to all children and families and accepted by all but
a very few. They are therefore the foundation stones of any arrangements to
safeguard and protect children within an area. Targeted and protective services
are fully reliant upon Universal Services to correctly identify those children and
families in need of additional support or intervention sufficiently early. Without
robust safeguarding arrangements within Universal Services, tragedies will occur
involving children.
48
11.6. The WSCB was determined from the outset to gain a thorough and detailed
understanding of all of the events leading to Child C’s death, seeking in earnest
to identify if any lessons could be learnt from the case and to strengthen
safeguarding arrangements locally. The WSCB made a firm commitment from the
outset to ensure that any necessary change would occur leading to
improvements within the services as a result.
11.7. With this in mind, together with the fact that the major part of the report was
written before any guidance suggested otherwise, the level of detail within the
analysis section is greater than may occur in other SCR reports, as the Universal
Services provided to the family are analysed in depth.
11.8. The key lines of enquiry have been addressed under the following themes
identified during the review.
Critical Analysis of the Support offered to the Family before
6th December (Includes Key Lines of Enquiry 1. 2. 3. 4. 5. 6. 10.)
11.9. From the start of the pregnancy with sibling FGU to the death of Child C, the
family were only ever in receipt of universal health services, along with some
specialist hearing and language services.
11.10. They were never known to social care until after the death of Child C, and no
previous referrals for the family were ever made to children’s social care.
11.11. The panel looked in some detail at the service provided to the family. The key
learning for the Review from the support provided to the family is analysed in
this section.
11.12. The universal health services provided to the family consisted of:
Midwifery
Health visiting
GP services
11.13. The specialist hearing and language services provided to the family were:
Audiology services hosted by Bridgewater Trust
49
Hearing Support Teacher services
Speech and Language therapy.
11.14. The Review has identified areas of poor communication and information sharing
between the community services supporting the family. There was also a
tendency to deliver task orientated services, and for practitioners to not see the
bigger picture. Effective communication is necessary if practitioners are to be
able to function effectively, make appropriate assessments and not work or think
in silos. There are many lessons within this case to be learnt about improving
communication and liaison in casework with families. A recurrent theme in the
Serious Case Reviews involving babies evaluated by Ofsted (2011) was the need
for better co-ordination between the different aspects of health provision. The
Ofsted report highlighted a particular emphasis on failings in the transfer of care
between midwifery services, health visitors and GPs.
11.15. Community midwifery services, along with hospital maternity care are provided
by Wrightington, Wigan and Leigh NHS Foundation Trust. Community midwives
are usually the first contact for the expectant woman during her pregnancy and
throughout labour and the postnatal period. They assist women to make
informed choices about the services and options available to them by providing
as much information as possible, and working in partnership with other
healthcare professionals.
11.16. The health visiting service was provided by Bridgewater Community Trust.
Health Visiting teams are based in Clinics or Health Centres and in Wigan are
responsible for cases allocated to them using the Corporate Caseload model of
working. Corporate Caseload working is a term used to describe a Health Visiting
Team having joint responsibility for a client population within a geographically
defined caseload. It also requires that Health Visitors merge their individual
caseloads to form a single combined one whilst maintaining accountability for
individual clients.
11.17. The Health Visiting service incorporates the Healthy Child Programme
(Department of Health 2009). The Healthy Child Programme supports the model
of progressive universalism. It is a core universal programme for all children with
additional contacts provided for those with identified needs. There is an
emphasis on integrated services across General Practice and Children Centres led
by a health visitor and delivered by a range of practitioners across the health
service, including midwifery, and the wider children’s workforce.
50
11.18. GP services were provided from a mainly urban practice with a practice
population of 8,300. It consists of 6 GPs and 3 practice nurses. IG and her parents
had been registered at the practice for many years.
11.19. NU was registered at a different GP practice, one of the larger surgeries in the
locality, whose catchment area includes two substantial housing estates with a
high incidence of unemployment. The centre also reports a higher than average
chronic disease prevalence amongst residents.
11.20. The Children’s Hearing (Audiology) Service records for FGU indicate that FGU was
seen on ten separate occasions. These contacts were in relation to:
diagnostic audiology testing;
monitoring of hearing;
fitting of hearing aids and review of hearing aids.
11.21. The Specialist Sensory Education Team (SSET) provides support to pupils from
birth who have hearing loss and /or visual impairment. It is one of five specialist
targeted teams who work borough wide within the Early Intervention and
prevention service. The services to FGU and Child C were delivered via a Hearing
Support Teacher (HST).
11.22. Some brief interventions from the speech and language therapy service were
also received by the family consisting of two home visits to FGU. FGU was
diagnosed with a language delay. There was one ‘no access’ visit undertaken by
the speech and language therapy service and there is further information to
suggest some difficulties in contacting the family by telephone.
Critical Analysis of the support to the family provided by the Midwifery service
11.23. When IG was pregnant with FGU, the midwives identified three predictive risk
factors of post natal depression in IG which they shared with the health visiting
service in the Notification of Pregnancy Form. This did not prompt any antenatal
contact from the health visiting service nor any additional input from the
midwives as the criteria for additional contacts had not been met in either
51
service. The guidance within the Healthy Child Programme allows for one or two
structured listening contacts when women have low self-esteem and relationship
problems or brief non directive counselling to be provided over 4-6 weeks when
women have non clinical symptoms of depression. It was the view of the Panel
Member for Wrightington Wigan and Leigh NHS Foundation Trust that these
contacts would need to be offered by the health visiting service, as there is
nothing within the national Midwifery Pathway locally agreed processes which
would link with the Healthy Child Programme at this point and have afforded any
additional service to IG.
11.24. NHS England are responsible for commissioning the midwifery services, rather
than local commissioners. Wigan Clinical Commissioning Group commission a
local service from the regional midwifery specification. The guidance and
protocols for the midwifery service in place in Wigan is evidence based, but has a
focus on the early identification of puerperal psychosis and support for mothers
with other serious mental illnesses. It does not include the provision of support
for lower levels of mental health needs for pregnant women in Wigan, or further
communication with the health visiting service, even though the national
Midwifery Pathway is designed to support greater integration of the two
services.
11.25. In October 2010 the midwifery service saw first-hand the actual symptoms of
depression within IG when she was 31 weeks pregnant and IG described herself
as 'feeling down.' Something of a discussion is known to have taken place
between IG and the midwife but no further action was taken. There is no
documentation of the discussion and more detail in the records would have been
expected in view of a previous history of having had anti-depressants prior to the
pregnancy. There is no evidence of any communication with the health visitors or
GP, as would be expected within the Midwifery Pathway. This is in contrast to
the Midwifery Service Specification which states that the model of care provided
is integrated and aligned with services offered locally through GPs and health
visitors.
11.26. When FGU was born six weeks premature, there had been no previous indication
to the obstetric team caring for IG that there was to be any problem with FGU. It
was whilst in the neonatal unit that FGU was seen to have multiple physical
abnormalities of the face and head. The abnormalities will have been quite a
shock and difficult for IG to come to terms with. A conversation with a staff nurse
on the ward appears to be the only time that anyone ever had any conversation
with IG about what support she had at home.
52
11.27. The limited information within the midwifery notes mean that record keeping
standards were consistently not met by the midwifery service. The period of time
between the last hospital visit for FGU and the final visit from the community
midwife was deemed to be too long. The IMR states that the midwifery visits
should have been more frequent and planned better in light of the history of
depression, the emergency caesarean section and the birth of a premature baby
with abnormalities. The last visit by the community midwife on 28th December to
IG and FGU had all recordings ticked as normal, although the formal discharge
procedure was not followed.
11.28. There is no evidence of any handover to the health visiting service or
communication from the midwife about the family before FGU and IG were
discharged. Whilst it is understandable that pressures of work prevent such
discussions in routine cases, it is regrettable that the midwife, with her
knowledge of the previous history of depression in IG and the relationship
difficulties with NU, did not consider the family warranted additional attention
and that communication with the health visiting service, who were to take over
her care, was therefore needed. Nor did the midwife consider the implications
and additional stress on the family when IG delivered a baby with such obvious
facial deformities.
11.29. Little information has come to the Panel within the respective IMR about the
hospital or community midwifery service so it has not been possible to identify at
specific points within the chronology if the reduced level of service offered by
the midwife to IG was as a result of widespread service pressures, agreed
standards and protocols, or the misinterpretation of the level of need by
individual practitioners involved in the case. However, the Service Specification
for the midwifery services was subsequently submitted to the Overview author
by the Designated Nurse after the first draft Overview Report was submitted to
the Panel.
11.30. This ended the midwifery involvement with the family until on 25th March 2012
the maternity records show that IG was 16 weeks pregnant with Child C, was
weepy and unsure of continuing with the pregnancy. She told the midwife that
she wanted to have an amniocentesis to see if the baby had Treacher Collins
Syndrome as she had issues with the baby’s father.
11.31. On 19th June 2012, IG subsequently attended for a 20 week specialist scan. An
abnormality was identified on the scan leading to IG being told that she had an
80% chance that Child C would have Treacher Collins Syndrome. There is no
53
evidence in the chronology that the scan results were shared with any
professional involved with the family in recognition that additional support
would be needed by IG in light of the negative results. NICE guidance on Ante
natal care states that women who have experienced a baby with a congenital
abnormality (structural or chromosomal) usually require additional care.
Together with the requirements in the Midwifery Pathway, this care includes the
promotion of positive mental health and the emotional wellbeing of pregnant
mothers.
11.32. The community midwife was the obvious practitioner to offer further support to
IG at this time but, in contrast with the Service Specification which states that
the midwifery service offers support for women who are diagnosed with foetal
abnormalities, this support did not occur. The use of a Common Assessment
Framework assessment instigated by the midwife at this point would have also
brought in other professionals to support IG and may have explored further IG’s
emotional health and needs. However, it would appear that when IG told the
midwife the results of the scan on 21st June the midwife did not realise the
implications of FGU’s complex needs. The requirement to attend various
appointments already with one child, her facial deformity and the knowledge
that this could lead to bullying when she attended school. An enormous
unwelcome impact must have occurred for IG when she was told that it was
most likely she would have another child with the same condition and problems.
The Midwifery Service Specification includes the statement that the midwife is
responsible for initiating a Common Assessment Framework (CAF) for babies
with congenital malformations which will require additional support in order to
co-ordinate services to the family. The IMR from the midwifery service does not
analyse why the midwives did not complete a CAF in this case.
11.33. On 30th October Child C was born and an abnormality was immediately noted
leading to the diagnosis of Treacher Collins Syndrome when she was only 3 hours
old. There is no entry from the midwifery services either in the hospital records
or in the community midwifery notes to indicate that any enquiry was made
about how IG felt about the diagnosis, the extent of the impact on her, nor was
any additional support offered to her either in the hospital or at home by the
midwifery service.
11.34. There is also a lack of documentation by the hospital Trust which provided the
obstetric services about the wider social history of the family. There are no
indications of any enquiries being made about any parental mental health and
well-being or the parental capacity to cope with two children with complex
54
needs. The Midwifery Service Specification states that the midwife will take
responsibility for co-ordinating care to babies born with congenital
malformations, but this did not happen in this case and the reason why is not
analysed within the IMR.
11.35. The two pregnancy notifications to the health visitors from the midwifery service
contained conflicting and erroneous information. In May 2010 the notification
stated “Predictive risk factors for Postnatal Depression identified as:
Past family history of depression “mum – no treatment”
Relationship difficulties with partner
Unplanned pregnancy”
11.36. Yet in April 2012, the notification of pregnancy received by the health visiting
service stated that the midwives knew no predictive factors for post natal
depression.
Critical Analysis of the support to the family by the GP services
11.37. At the beginning of April 2010 IG consulted her GP presenting as tearful, quite
depressed and drinking alcohol to excess. She had left her boyfriend, and had
stress at work. The following month she presented back to the GP as seven
weeks pregnant with an unplanned pregnancy to a new partner. It is unlikely that
information about the background to the pregnancy was ever shared by the GP.
11.38. On 25th August 2011 IG presented back at the GP practice, again tearful and with
a low mood. She said she was depressed since going back to work and requested
a sick note and anti-depressants. The notes made at the consultation recognise
that IG had given birth to a baby with birth defects. This attendance was not
shared with health visitor. Nor was an attendance at the GP practice on 23rd
September with a 6 weeks history of depression and again when she was found
unfit for work on 13th April 2012 and given a four week sick note. Even if it is not
possible to share information about every mother who becomes depressed, the
additional factor of the stress of the birth defects should have made liaison with
the health visitor more appropriate and triggered a communication from the GP.
Reichman, Corman and Noonan (2008) found that having a disabled child may
increase stress, take a toll on mental and physical health and be associated with
guilt, blame or low self-esteem.
55
11.39. There is no evidence that the GP considered how these circumstances and the
depression would affect IG’s capacity as a parent. Anecdotally, IG has been
reported as having a confident and outgoing personality, yet the attendances at
the GP practice reveal a hidden troubled person who was struggling with her
circumstances. The SCR in Wigan for Child B had a recommendation for a
programme of training to meet the needs and requirements of GPs and their
staff to include as part of their training, guidance on specifically asking about the
effects of alcohol, drugs “and any illness or long term condition” has on the
ability to care for children. Clearly this is an area of challenge for GPs and needs
reinforcing.
11.40. The GP gave IG a sick note for 13 weeks on 6th January 2012. This could have
been because she still had not recovered emotionally from a recent miscarriage.
There was no indication that she thought she was pregnant again and no reason
for the sick note was recorded within the GP notes.
11.41. Furthermore there is no evidence that the GP was aware of IG’s hearing
problems, and the recommendation that she needed hearing aids. This
information should have come to the GP in a letter from the audiology
department but is not found within either the GP chronology or the chronology
from Bridgewater Trust.
11.42. The GP practice have, however, been able to evidence many examples of good
practice, including the use of standardised tools for the assessment and
gathering of information when a patient presents with possible depression.
11.43. With regard to communication with the health visiting service, the problem
appears to lie with the Bridgewater protocol on communication between the GP
practice and corporate health visiting teams. This places a requirement on the
health visitors to supply information to the GP practice on:
local organisational matters,
those families evaluated by the weighting tool as Blue or Red.
those families where children are subject to a plan or any concerns
Also, to collect information about patient transfers and pregnancy notifications.
11.44. However, the protocol offers no guidance to the GPs whatsoever on what
information about children and families that should trigger a communication to
the health visitors. This is a very worrying situation and means that there is no
consistency or baseline practice with regard to information sharing between GPs
56
and health visitors across the Borough. GPs are well placed to identify important
issues that affect family well-being. Such issues on their own may appear
insignificant, but when combined together with other factors or circumstances
known to the health visitor, can lead to the identification of family stress or
safeguarding concerns that warrants either a risk assessment or reassessment of
need by the health visitor. Without some defined arrangements and information
sharing agreements in place for the GPs to liaise with the health visitors about
significant matters that may affect parenting capacity, the result is that the
threshold for being able to successfully identify needs and concerns becomes too
high a level for effective preventative work with families. The matter of
communication between the GPs and health visitors is now being addressed by a
working party as a result of this SCR.
11.45. It is of note that there was no liaison between the GPs and health visitors about
Child C’s family until after Child C died.
Critical Analysis of support to the family from the Hearing Support Teacher
11.46. The report from the Specialist Sensory Education Team (SSET) Service documents
that FGU had been assessed to receive 16 hours of support per year under the
allocation matrix. For preschool children the role of the Hearing Support Teacher
(HST) includes “to advise/teach the parents, support the nursery, support/liaise
with agencies.”
11.47. This service sits within the Early Intervention and Prevention Service within the
Local Authority.
11.48. Over the course of the twenty five months that the Hearing Support Teacher
was involved with the family from January 2011 to February 2013 she undertook
19 home visits, saw the family at 12 further clinic visits as well as undertaking 3
visits to the nursery, along with telephone calls and liaison regarding the
Disabled Living Allowance claim. Child C was seen 3 times by the Hearing Support
Teacher (HST). It is a matter of record that there was no contact ever made from
the HST to the health visiting service.
11.49. Despite this intense level of contact, there is no evidence of any assessment ever
being made by the Hearing Support Teacher of the families’ ability to meet the
needs of two children with disabilities. The only focus appeared to be on the
57
hearing aids for the children. At a time when services elsewhere are under
threat, this narrow focus has implications for service provision.
11.50. The Hearing Support Teacher describes having a “supportive friendly working
relationship, mostly with IG, but also to a lesser extent NU”. The HST has 40
years of service in this specialism and the service provided one consistent
practitioner for the family in order to provide continuity of care.
11.51. However, very little is documented by the HST about IG or NU, and a wider
problem of insufficient note taking and recording within the service is thought to
have developed over a period of years which is now being addressed as a result
of this SCR.
11.52. On 14th January IG told the audiology service that she had problems with her
hearing and that she had been told when she was 4 months pregnant that she
needed hearing aids. The audiologists went on to test her hearing as she was so
upset. The Hearing Support Teacher did not appear to glean this information
from the audiology records or from the contact she had with her colleagues in
that department. She worked closely with the audiology service and attended
clinic sessions in the audiology department where she had access to the records.
This matter has identified a gap in the way in which information is shared
between the two services (audiology and Hearing Support Teacher) about adults.
Critical Analysis of family support provided by the health visiting service
11.53. The health visiting service is the universal service which provides long term
support to pre-school children and their families. The service acts as a gate
keeper and receives information from widespread sources depending upon the
circumstances of a particular family. There is an expectation that the service
consequently undertakes assessments and reassessments of the level of support,
and in appropriate cases, risk, within families as a result of the information held
within their records.
11.54. The Review considered the service received by the family from the health visitors
and asked whether this level of service was appropriate?
11.55. On 15th December 2010, after the birth of FGU the health visiting caseload
dependency tool was completed resulting in the family identified as “Blue”. This
meant that the family were assessed as requiring high levels of intervention from
58
the health visiting team – a minimum of monthly face to face contacts being
required. The rationale for this assessment was:
FGU was born with cleft palate and Treacher Collins Syndrome
IG was a single mother with a query of mild learning difficulties.
11.56. The Caseload Dependency Tool in use at the time of FGU’s birth was a tool
adapted from a tool used by Health Visitors at another Trust. The categories
were identified as ‘red’, ‘blue’, ‘amber’ and ‘green’. ‘Red’ would require the most
intensive visiting pattern whereas ‘green’ would indicate the least intensive.
11.57. In any event the family did not receive the monthly visiting pattern that this tool
had said the family warranted. FGU received three home visits in 2011 including
the birth visit, and three visits (although one was cut short) in 2012. FGU
attended well baby clinic seven times between February 2011 and September
2011. Health Visitor 1 explained that she had later assessed FGU as a ‘green’ and
that by the time Child C was born the family were already ‘green’, and that by
the time Child C was born she felt that the family needed no additional support.
11.58. It has become apparent in the report to the Panel that the caseload dependency
tool has not been embedded into practice and there is evidence of confusion
with its use by health visitors. Numerous amendments and multiple variations of
the tool used different terminology. No version control was used which was
hampered further by the process of disseminating the changes via emails or
memos instead of providing training for staff.
11.59. Health Visitor 1 agreed with Health Visitor 2 for an assessment of the family as at
level 1 (green) yet wrote on the referral form for the Transport Service that FGU
had “complex needs .“ The simple fact that the health visiting service was
involved in arranging Transport for Sick Children proved that Child C was not
‘Level 1 – Universal’.
11.60. At the new birth visit to Child C by Health Visitor 2, the health visiting caseload
dependency tool was again completed identifying the family as Level 1- Universal
Criteria as per Healthy Child Programme. This assessment did not recognise the
increased risk of vulnerability for children who have a disability or additional
needs, or indeed for families who have more than one child with a disability. The
Healthy Child Programme, in fact sign posts the health visitor for a package of
additional support and monitoring to be provided when babies are born with
health problems or any abnormalities, and thus the caseload weighting tool was
59
flawed from the outset in not including the specific wording from the guidance
about babies and children with “abnormalities”.
11.61. The birth visit was the only visit or contact from the health visiting service with
the family before Child C suffered a fractured skull on 6th December, a fact which
is of particular relevance when the actions and decisions taken by the health
visitor as a result of this injury are considered.
11.62. What was working well was the system by which the health visitors were
receiving a constant supply of letters from the hospital appointments that they
were copied into. When a child attends hospital to see a medical professional, it
is not unreasonable that the consultation is focused around a specific area of
speciality, and there is little time to look at the wider family. This is why copies of
letters are sent to the health visiting service as this service is designed to focus
on the wider needs of the family.
11.63. The letters provided additional information from a secondary source which was
adding to the assessment of the family but by which the health visitors were
erroneously reassured and reliant upon. The family were appearing to be coping
because they were achieving attendance at their many appointments and all
seemed to be going well. This hearsay assessment by the health visitors was not
providing a direct service to the family in the form of face to face contact and
support which would then feed into an assessment from first-hand information.
11.64. There is a difficult balance to be maintained with regard to support when
families have children who attend numerous appointments. Some parents feel
that they have enough pressures on them from the existing appointments and
see the additional visits from the health visitor as yet another session in an
already overcrowded weekly diary. They crave the time to be left alone and try
and achieve some normality of family life.
11.65. This can cause many health visitors to back off from visiting families with
multiple appointments, when what the families often need is help to co-ordinate
the appointments from a Lead Professional. However, in many cases parents can
feel completely lost and overwhelmed by the attention focussed on their child by
the various health professionals who concentrate on their particular area of
specialism for the child. This is often coupled with feelings of guilt and aspects of
grief as parents come to terms with the fact that their child’s life may not be
normal. Parents often feel guilty or uncertain about admitting the level of stress
that they are under when they have a child with complex health needs and often
60
need to be “given permission” by the health visitor that this is a normal reaction,
but commonly the only way in which this happens is if the health visitor brings it
in to the conversation and the family know and trust the health visitor well
enough to feel safe in making the admission.
11.66. The health visitor may well be the only professional who will focus on the
supporting both the parents and children in a holistic way. The Ofsted Thematic
Review (2012) found that some parents found it difficult to accept that they
needed support.
11.67. Thus health visitors who visit families with children with complex needs or
multiple appointments need to use assertive outreach skills in talking to parents
directly about the impact of those needs on the entire family. The health visitors
should be very proactive and tactfully share with the family that there is an
expectation that they would usually receive additional support visits from the
health visiting service. The service would then offer more frequent appointments
with the family, although the family have the ultimate choice to decline or
postpone them. This would be consistent with the Healthy Child Programme
which recognises that from birth until at least 3 years, children with
developmental problems or abnormalities should be offered a package of
additional support and monitoring.
11.68. The service provided by the health visitors was of a very good standard when
they saw the family of Child C, and the detail of records of the home visits were
also to a very good standard. However, the level of service offered was less than
what should have occurred as a result of flaws within the caseload weighting tool
and the need to train staff further for work with children and families with
disabilities.
11.69. The service are correctly going to some lengths to increase the engagement that
it has with the males who live in households, which is good practice, but this can
present other challenges with regard to domestic abuse screening. On 30th
January 2012, the health visitor visited the home and quite correctly did not
complete the local screening tool for domestic abuse because NU was present.
However, there is no record of any intention to follow this up and ensure that
the tool was completed. It is unclear what the guidance is for health visiting staff
in Wigan in such circumstances.
11.70. There is evidence that the Chronology of Significant Events Form was not always
completed by the health visitors and vital entries were missing from this
61
document. This was particularly important after the 6th December when the
health visitors missed when the level of vulnerability within the family was
increasing, and thus missed an opportunity to intervene with the family.
11.71. During her 16 weeks of life, Child C only had two home visits by the Health
Visiting Service.
11.72. Whilst the corporate caseload model of service for health visitors is a good
model for ensuring that workloads are balanced amongst the staff across a
service, it very easily produces a more task orientated delivery of service than
the personal care and follow up of individual caseload responsibility. Contacts
under the corporate caseload model are often with several members of the
health visiting team, rather than the model facilitating a child and family centred
continuity of care approach. The report from Bridgewater highlights this matter
as a concern and as a result the corporate caseload system is currently under
review in Wigan.
11.73. Staff from all disciplines working in the community have a responsibility to assess
the wider needs of the family. It is recognised in guidance that they are in a good
position to recognise early signs of family stress or safeguarding concerns, and to
instigate appropriate responses.
11.74. It would appear from the reports and chronology that no one ever asked the
parents about how they really felt about their children’s condition.
11.75. All along the professionals involved in the care of the family from all of the
different disciplines made the same dangerous assumption that if the family had
coped well with one child with additional needs, then they would cope with two
children with additional needs, when in fact this would only serve to increase the
demand on both parents. Instead, there was no recognition of any increased
vulnerability or family stress after the birth of Child C. The Ofsted study of
Serious Case Reviews (2011) identified that the risks resulting from parents own
needs were often underestimated in SCR cases involving babies.
62
Impact of Disability on the Family and the level of Family
Support
(Includes key lines of enquiry 1. 2. 4. 6. 9).
11.76. It is clear from the reports that a difference of opinion exists by the various
professionals as to whether or not FGU and Child C were disabled because of
their Treacher Collins Syndrome, and that this opinion directly influenced the
level of service that the family received. Research on the protection of disabled
children indicates that they are more at risk of being abused than non-disabled
children (Ofsted. 2012).
11.77. The Bridgewater IMR analysed in detail the question as to whether or not
someone who has Treacher Collins Syndrome is disabled and it is worth
replicating some of that analysis here. The report compared the definition under
the Equality Act 2010 where by someone is considered disabled if they have a
physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative
effect on ability to undertake normal daily activities. ‘Substantial’ being defined
as ‘more than minor or trivial’ and ‘long-term’ means for 12 months or more. It
could therefore be argued from this definition that someone with Treacher
Collins Syndrome would not be classed as ‘disabled’. This is in contrast with The
Children Act 1989 – Section 17 whereby a child is disabled if: “he is blind, deaf or
dumb or suffers from mental disorder of any kind or is substantially and
permanently handicapped by illness, injury or congenital deformity or such other
disability”
11.78. Treacher Collins Syndrome is listed on many internet sites offering information
and access to support for disabled children. However, the range of the facial
characteristics of the syndrome can be so mild as to go unnoticed. Learning
disability may be a feature of the syndrome but is not commonly so. Children
with bone anchored hearing aids and Treacher Collins Syndrome do well.
However the psychological and social problems associated with facial deformity
may affect the quality of life in many people.
11.79. The author of the Health Overview Report states that the management of
Treacher Collins Syndrome needs a multi-disciplinary approach and may involve
the intervention of different professionals.
11.80. There is no evidence that either the health visitor, Hearing Support Teacher or
the midwives ever explored the coping mechanisms or ability of the parents to
63
adapt to having a second child with additional needs. Living with a disabled child
can have profound effects on the entire family, which in turn can affect the
health and wellbeing of the child who is disabled (Reichman et al. 2008).
11.81. As discussed above, the midwifery service was responsible for the provision of
services when IG was told she had an eighty per cent chance that Child C had
Treacher Collins Syndrome. Whilst further screening tests would have been
offered, the midwives showed no evidence of undertaking any new assessment
of the family as per the Midwifery Pathway, or providing additional emotional
support or service once the scan results were known.
11.82. The SSET report on the work of the Hearing Support Teacher found little work by
that service focussing on the disability needs of the family, other than the
support for the Disability Living Allowance benefit, which does evidence that the
service considered that disability was a factor within the family.
11.83. Yet it is evident from interviews with the health visitors and the Senior
Audiologist involved with Child C, that Child C was not viewed as having a
“disability”. Senior Audiologist 1 has the view that she would not perceive a child
with Treacher Collins Syndrome as disabled if they wore their hearing aids. She
qualified this opinion by explaining that in Treacher Collins Syndrome there are
usually no problems with the cochlea and no problems with the transmission of
sound once hearing aids are fitted.
11.84. The health visitors perceived IG and NU as being able to meet Child C and FGU’s
needs. In addition, Health Visitor 1 described the family as “a nice family”
11.85. Thus several of the practitioners involved with FGU and Child C did not assess
the children as being disabled nor were the children assessed as being a ‘child in
need’. At best, they viewed the children as children with additional needs whose
needs were being met by the parents and by the professionals involved.
11.86. It is uncertain if the family saw themselves as a family in need. Certainly they
looked for support from the transport services because of multiple
appointments, and financial aid in the appeal for the DLA benefit. The children
did not suffer from any global developmental delay so did not reach the
threshold for services from the Child Development Centre which was the
gateway to other support services.
64
Lead Professional and the Common Assessment Framework
(CAF)
(Includes Key Lines of Enquiry 1. 2. 3. 4. 6.)
11.87. The Common Assessment Framework (CAF) is a process whereby practitioners
can identify a child's or young person's needs early, assess those needs
holistically, deliver coordinated services and review progress. It is designed to be
used when a child's or young person's needs are unclear, or broader than the
practitioner's service can address. According to Department for Education the
CAF should be offered to children who have additional needs to those being met
by universal services.
11.88. The IMR for the SSET service states that the Hearing Support Teacher (HST)
provided the parents with extra time-consuming support around phone calls,
letters and form filling because she believed that they had some degree of
learning disability. There is no evidence in any of the records available to this
Review that either IG or NU were diagnosed with any degree of learning
disability. There is no evidence that the HST took any steps either to confirm her
suspicions or, as should have happened, to liaise with any of the other agencies
involved with supporting the parenting capacity of the children, such as the
health visitor. The report recognises that the supportive nature of the Hearing
Support Teacher service was on a limited area of the needs of the children and
parents, and that links with the health visiting service would have supported
communication about the family.
11.89. In fact the view of the panel members was that the Hearing Support Teacher did
not see herself in a safeguarding role. Nor did she see it as her job to consider
the impact on parenting capacity that the mother’s suspected learning disability
had. This worker spent more time with the family than any other professional yet
she said for the purpose of this Review that she did not have detailed knowledge
of them, and knew nothing about the family. The Panel agreed that it is of
concern that the systems had allowed for the development of such narrow
thinking and working within an experienced practitioner. Indeed, it was
suggested that some of the role as delivered to the family by the Hearing
Support Teacher could be undertaken by an unqualified support worker. The
Panel hold the opinion that the HST team need to see themselves embedded in
the wider context of support for families and with responsibilities to safeguard
65
and promote the welfare of children, yet the report for the service does not
sufficiently reflect this.
11.90. The suspicion that IG may have had some learning disability was also held by two
of the three health visitors involved with the family. This suspicion was based
around evidence that IG was at times slow to respond to questions and was
seeking assurance from FFG, with the need for information to be repeated or
rephrased, raising doubts about her level of comprehension. However, the third
health visitor refuted this and said that IG was able to converse freely and
openly. It may be that the observations of the first two health visitors were made
as a result of IG being hard of hearing. Certainly, with the level of hearing loss
that she suffered, IG would have had difficulty in hearing the children cry. There
may have been delays in her responding to the children as a result of her hearing
loss, and some more prolonged periods of crying. It is possible that NU had
learning difficulties as a result of his Treacher Collins Syndrome, but this was not
identified as an issue throughout his schooling and he worked full time in a
manual occupation.
11.91. In both cases, the Hearing Support Teacher and the health visitors should have
identified the need to undertake an assessment of IG’s parenting capacity when
they suspected she had learning difficulties. There is no record that this was ever
considered, or that any practitioner ever checked to see if a CAF had been
completed on the family. The assessment may well have been declined by the
family, but should still have been offered. The instigation of a CAF may have
prompted IG to tell the health visitors about her hearing difficulties.
11.92. In fact the Panel heard that IG attended a mainstream school and that no
significant health issues were identified within the records of this time. However,
the suspicions held by the Hearing Support Teacher and both health visitors
should have prompted a decision to consider a Common Assessment Framework
(CAF).
11.93. Training for the SSET on wider observations and partnership collaboration is to
be provided, particularly focussing on cases where children and families may
have wider unmet needs which need to be linked into the CAF process.
11.94. This SSET eligibility criteria form is to be amended to look to ask more specific
questions around parental histories and vulnerabilities to help the HSTs in future
make better assessments overall, but this will only work if there is professional
curiosity and respectful enquiry. The form will also need to include a section on
66
whether a CAF (Early Help) assessment should be considered. A new supervision
template and procedure is also currently being drafted as a result of learning
from this review.
11.95. There was a failure to recognise the profound effect that living with a disabled
child can have on a family. Uncertainty about the future, financial and emotional
demands as well as the pressures of planning around appointments is highly
likely to lead to family stress. Guilt or blame is often a factor for the parents.
11.96. Health Visitor 1 did not complete a CAF as she believed that all of the family’s
needs had been met and because Child C’s family were attending all of their
appointments. However, she stated she would have completed a CAF if that had
not been the case. In addition to this, Health Visitor 2 asserted that as no other
agencies were involved with Child C’s family, a CAF was not indicated because
Child C and FGU’s needs were being met within the span of a single agency.
11.97. If a CAF had been completed for the family, then a Lead Professional would have
been appointed. The Lead Professional has the responsibility to support the
delivery of a seamless and effective service by acting as a single point of contact
and ensuring that services are well coordinated, consistent and delivering to the
needs of the child and family. It is apparent that in this case no practitioner
undertook any leading role for the family.
11.98. IG had two children under the age of 3 years both with Treacher Collin’s
Syndrome requiring multiple attendances at clinics. That the family had some
needs was recognised in that transport services were provided but otherwise
there was no recognition by the midwife, Hearing Support Teacher, health
visitor, or GP of the need for further intervention and possibly a CAF.
11.99. The Panel were already aware before the review commenced that there was
reluctance within the Borough to initiate the CAF process. The appointment as a
Lead Professional is seen by practitioners locally as an additional workload which
they seek to avoid because they fail to understand the benefits both to the
families and to the agencies involved in their care.
11.100. Some agencies in Wigan are known to be more likely to initiate a CAF. The WSCB
had already agreed a strategy to address this matter with the workforce
including a full relaunch of CAF planned for the end of September 2013 including
a revised process and documentation.
67
11.101. It is a matter of conjecture as to whether if any professional had nurtured a
relationship with the parents that they would have been told about a level of
stress being experienced which could have been addressed somewhat, and also
as to whether or not that would have made a difference. However, someone
perpetrated significant and serious injuries to Child C for some unknown reason
and over a period of time.
6th December
(Includes Key Lines of Enquiry 1. 2. 3. 4. 5. 6. 7. 9, 10)
11.102. Child C attended accident and emergency at 11.22 hours on 6th December. She
was triaged by Staff Nurse 1 who took basic history from NU, checked the child’s
observations and then requested the accident and emergency Registrar Doctor 5
to examine her. Doctor 5 examined Child C and ordered a CT scan. A referral was
made for a paediatric opinion on Child C.
11.103. The request for the CT scan did not indicate any concern about how the injury
occurred to Child C. Yet the guidance within the Intercollegiate Report from the
Royal College of Radiologists and the Royal College of Paediatrics and Child
Health states “it is essential that when a senior clinician (usually a paediatrician)
has concerns about possible Non Accidental Injury (NAI) and they require a
radiological opinion that they convey their concerns clearly to the radiologist. The
possibility that a child has been injured non accidentally should be clearly stated
on the radiological request “
11.104. There was also no mention of the possibility of NAI on the referral form
completed by the general accident and emergency registrar. If the Hospital Trust
do not expect their general accident and emergency registrars to be familiar with
the above paediatric guidance then there should be some arrangements within
the Trust governance systems to compensate for this. This could mean that the
paediatricians review the CT requests and submit any additional information, and
any child protection differential diagnosis to the radiologists as necessary. This
did not happen in the case of Child C and as a result the radiologist was not
alerted to any concern about the case. Nor could he then provide the safety net
of advising if any other x-rays such as a skeletal survey should be considered.
Research shows that babies and toddlers are more susceptible than older
children to non-accidental head injury, resulting in significant brain injury.
68
11.105. Doctor 1 a paediatric middle-grade doctor then came to see Child C and an
assessment and examination was undertaken. The plan made by Doctor 1 was to
chase the CT scan report and admit Child C to the paediatric ward for
observation as is standard practice following a head injury.
11.106. Doctor 1 has recorded a comprehensive description of the injury sustained by
Child C, in keeping with good practice. However there was a lack of
documentation of any wider assessment of Child C including her environment,
birth history, family and social history.
11.107. When Doctor 1 was asked about the assessment he took, he replied that he did
not explore any further anything about the family and social history, including
any past medical history. However he did say that he observed the parents’
ability to care for the children and that nothing struck him as unusual.
11.108. As will be explained further in the report, Doctor 1 was under a considerable
workload pressure at the time, and this was his reason for not undertaking a
more detailed history.
11.109. In trying to understand the reason for the decision making that followed over the
next two days, it is helpful to understand the psychology theories of Cognitive
Bias and the Halo Effect.
11.110. Cognitive biases, written about extensively by Daniel Kahneman, can be
characterised as the tendency to make decisions and take action based on
limited acquisition and/or processing of information. They are mental errors
caused by our simplified information processing strategies at subconscious level.
11.111. The Halo Effect or Halo Error, identified by Throndyke, is a cognitive bias in which
one's judgments of a person’s character can be influenced by one's overall
impression of him or her.
11.112. The Consultant Radiologist stated the scan showed “it was a large fracture to the
skull, but there were no indications on the radiology request card that it was a
suspicious injury. It is usual practice if there is suspicion of non-accidental Injury
that the card is marked NAI and the Paediatrician usually contacts the
radiologists to discuss the scans, this was not the case for Child C”.
11.113. The evidence of a large fracture in a five week old baby who is disabled and
immobile should have aroused suspicion with Doctor 1. The Health Overview
69
report includes reference to studies showing that fifty percent of fractures in
children under 18 months are as a result of child abuse.
11.114. The age of the child, the severity of the injury and the mechanism of the injury
should have aroused some suspicion and it would have been standard practice to
make a referral to Social Care Central Duty Team in accordance with both the
Trust “Bruising in the Immobile Child Policy” and NICE guidance “When to
Suspect Child Maltreatment”.
11.115. Doctor 1 has stated that at the time he considered the injury to Child C to be
accidentally caused, yet the following account showed his subsequent actions in
the management of the case to be increasingly inconsistent with that opinion.
11.116. Doctor 6, a junior doctor involved in Child C’s admission, noted that the history
given in accident and emergency and that given to the paediatric doctor were
inconsistent and recorded an intention to discuss this with the senior doctors.
This query about the discrepancy appeared to be subsequently clarified in the
notes which were made by Doctor 1 on 7th December who stated he had
reviewed the history, was then satisfied with the story given by NU and classified
the injury as accidental. However Doctor 1 also wrote in this entry that the plan
was to contact social care if there were any concerns.
11.117. It is apparent from the chronology that by this point in time, the history had
been taken from the family at least twice, although one of the concerns
discussed at Panel meetings was the lack of clarity that occurred sometimes
throughout this admission when looking at the chronology as to whether the
history had actually been re taken from the family by a clinician, or if the history
was being copied from an earlier entry in the notes. Throughout the admission
there are at least five different accounts of how the injury occurred recorded in
the medical records, but this was never recognised or given any degree of
significance.
11.118. The Panel have queried why Child C had an injury on the left side of her head
extending around to the rear, when the story would suggest that the injury may
have more likely occurred to the front of her head, as at 5 weeks old Child C
would have had limited head control.
11.119. The Panel would have preferred to see more specific detail recorded when the
histories were taken by the hospital staff, as a minimum standard of practice.
This would include recording the exact words that the parents or carers used,
records of any challenge made to the parents about any detail of the account,
70
and confirmation of what was being recorded from previous entries in the notes
as opposed to what was being told to the staff at the time. This is a training issue
for the Trust. Recommendation 68 of the Laming Enquiry into the Death of
Victoria Climbie states “When concerns about the deliberate harm of a child have
been raised, doctors must ensure that comprehensive and contemporaneous
notes are made of these concerns. If doctors are unable to make their own notes,
they must be clear about what it is they wish to have recorded on their behalf.”
11.120. Doctor 1 remembered that NU did most of the talking upon Child C’s admission
and IG sat quietly. The nursing notes record that NU stayed on the ward with
Child C and did all of her care, appearing to handle her well. IG was remembered
as being a very quiet person often sitting and observing the interaction between
NU and their children. No attempt was ever made to probe these observations
with IG. The Panel did consider whether or not this could be a symptom of the
control exerted in domestic abuse situations but the Review found no other
evidence of possible domestic abuse in this relationship.
11.121. At 5pm on the 6th December and the end of Doctor 1’s shift, there is no
indication of a hand over for Child C to the consultant on call overnight. If the
case had been subject to a handover that evening, as required by one of the
expected Department of Health Standards of Practice within paediatric care, it
would have given the opportunity for an experienced consultant to review the
case and review the initial decision of accidental injury. This was an opportunity
that Doctor 1 failed to take advantage of, and it is unclear why he did so in light
of his uncertainty about the case which was becoming apparent.
11.122. At 11.30 am on 7th December, Doctor 1 undertook what was known in the Trust
as the “Hot Week Consultant ward round”. He did not see Child C as she was in
the ophthalmology department attending for a previously arranged
appointment. This ophthalmic examination could have helped to rule out or
indicate the possibility of NAI, and it is unclear if Doctor 1 knew the results of
that examination at the time of the ward round. Nor did Doctor 1 look at the CT
scan himself as he said he preferred to leave this to the experts. Nonetheless he
then took the decision about Child C to probably discharge her later that day as
her condition was stable. Recommendation 79 of the Laming Enquiry into the
Death of Victoria Climbie states “During the course of a ward round, when
assessing a child about whom there are concerns about deliberate harm, the
doctor conducting the ward round should ensure that all available information is
reviewed and taken account of before decisions on the future management of the
child’s case are taken”
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11.123. During the week which included 6th and 7th December, Doctor 1 was covering for
the Consultant Hot Week, and it is important to understand what this meant and
the impact of this additional workload. When a vacancy at consultant level had
occurred within the paediatric team some time previously, the Trust decided to
withdraw the post as part of the Cost Improvement Programme money saving
initiative which is now required of all NHS Trusts. A discussion had subsequently
been had with the remaining Consultants and it was agreed that the middle
grade registrars would be expected to take it in turns on the rota to act up to
being a consultant every six weeks as a training opportunity. This would
however, also have a consequent adverse effect for the middle grade doctors
though, as there would be less middle grade doctors to support the consultant
on call at this time. That week Doctor 1 was covering the paediatric ward, the
neonatal unit, and accident and emergency. The Hot Week arrangement to
include the middle grade doctors has now ended at the Trust as a result of the
Rapid Appraisal which occurred when this case came to the attention of the
WSCB Critical Incident Review Group and the consultant rota is now covered by
the consultants at all times.
11.124. At any point during Child C’s admission, Doctor 1 could have taken advice about
the case from the on call consultant, or the consultant on call overnight as part
of the handover process, but it would appear that he did not utilise these
resources available to him. It is not certain if Doctor 13 the clinical director was
the on call consultant that week, but in fact Child C was listed as being admitted
as a patient of Doctor 13. Recommendation 76 of the Laming Enquiry into the
Death of Victoria Climbie states “When a child is admitted to hospital with
concerns about deliberate harm, a clear decision must be taken as to which
consultant is to be responsible for the child protection aspects of the child’s care.
The identity of that consultant must be clearly marked in the child’s notes so that
all those involved in the child’s care are left in no doubt as to who is responsible
for the case”. There is no evidence within the chronology that Doctor 13 had any
involvement in the decision making or management of Child C.
11.125. Indeed, he probably had no knowledge of Child C until the discussion at the Peer
Review meeting. The hospital Trust needs to take immediate steps to ensure that
this recommendation from Lord Laming is fully embedded in practice.
11.126. On 7th December, despite having told the parents that Child C would be going
home that day, there is evidence from his actions that Doctor 1 was unsure of his
diagnosis of an accidental injury and that he did seek to repeatedly discuss the
case with other consultants.
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11.127. Doctor 1 discussed the case in the Friday X-ray review meeting at 12md. The X-
ray review meeting is an informal one where consultant radiologists, consultant
paediatricians and junior doctors meet to discuss cases of interest.
11.128. Doctor 3 was present at this meeting and was very positive in his comments
about the family to Doctor 1, although this information needs to be seen in
context. Doctor 3 said that he knew the family, that they were good people, who
always attended their given appointments and that he had no concerns about
them.
11.129. Using the theory of cognitive bias, it would appear that cognitive bias may have
occurred within Doctor 3’s rationale when he expressed the view that the cause
of the injury was accidental. His automatic and immediate response was that this
was a nice family. The theory of cognitive bias holds that a person’s ideas,
thoughts and emotions come quickly to their minds through an associative
process. From this response or conclusion, the theory states, the natural move is
to then mentally produce an argument to support that conclusion.
11.130. The effect of cognitive bias has also been recognised in the study by Brandon et
al (2009) where there was reluctance amongst many professionals to make
negative judgments about a parent, as they become rigid in their thinking and
struggle to revise their views.
11.131. When Doctor 3 said that the family where a “nice family” he was really in fact
only referring this judgement to the parents as the children were so young.
Difficulty in maintaining a focus of the needs of the children in a family over
those of the parents is an on-going challenge for practitioners and one which has
been recognised as problematic again and again ever since the case of Jasmine
Beckford in 1984.
11.132. Doctor 1 was clearly still uncertain or seeking further reassurance about the
diagnosis, because at 15.00 hours Doctor 1 also discussed the case with Doctor 8
at the beginning of the child health directorate meeting. Doctor 1 was of the
understanding that Doctor 8 was acting Named Doctor as the usual Named
Doctor was not in work that day.
11.133. Section 2.112 of Working Together to Safeguard Children 2010 requires all NHS
Trusts to identify a Named Doctor and a Named Nurse for Child Protection.
“Named professionals have a key role in promoting good professional practice,
and provide advice and expertise for fellow professionals…. They should have
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specific expertise in children’s health and development, child maltreatment and
local arrangements for safeguarding and promoting the welfare of children”
11.134. Doctor 8 was an experienced consultant paediatrician who had recently
relinquished the role of Named Doctor for the hospital. It is the opinion of Doctor
8 that he was not acting as Named Doctor that day nor was he being asked to get
involved in the case, but that he recognised that Doctor 1 was worried, and
therefore Doctor 8 gave him some advice which was to contact social care and
the health visitor, and to consider a skeletal survey if there are any concerns. He
did not advise Doctor 1 to consult the Trust child protection staff.
11.135. At this point, with the previous experience as Named Doctor, it would be
reasonable to expect that Doctor 8 would be aware that a study by Brandon
(2012) had shown that 21% of children involved in Serious Case Reviews had
never been previously referred to social care.
11.136. The Intercollegiate Report from the Royal College of Radiologists and Royal
College of Paediatrics and Child Health Standards for Radiological Investigations
of Suspected Non-accidental Injury March 2008 states, “The premobile child is
less prone to accidental injury, and the younger the child, the more likely is the
fracture to have been inflicted. Children with disabilities are at increased risk of
abuse.
11.137. In children under the age of two where physical abuse is suspected, a full skeletal
survey should always be performed. There is sound evidence that a skeletal
survey has a high yield of revealing abusive fractures in children less than two
years of age”
11.138. If Doctor 8 did not believe himself to be the Named Doctor that day, and there
was any uncertainty as to who actually was, it would have been appropriate to
then direct Doctor 1 to approach the Designated Doctor for Child Protection to
seek advice on the management of the case, and Doctor 8, with his background
experience in the role of Named Doctor, would have known that this was the
appropriate clinical route to follow and action to take.
11.139. Doctor 1 could have also contacted the Named Nurse for Child Protection for
advice about Child C as she is an experienced and knowledgeable practitioner in
child protection, but he did not do so.
11.140. At 15.35 Doctor 1 spoke to Duty Team Social Worker 2, to enquire only if the
family were known to her agency. He did not share either the nature of Child C’s
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injury nor the explanation given. Neither the family nor the address were known
to social care. However, this enquiry was not recorded by the duty social worker
because it was not the expected practice within the service at the time. This
matter has now been rectified as one of the actions taken as part of the Rapid
Appraisal undertaken by the Critical Incident sub group of the WSCB as a result
of this case and all such enquiries are now recorded as a contact. The failure to
record this enquiry became significant in February when Child C presented as an
unexpected death and a further enquiry to social care was made.
11.141. The lack of formal involvement with social care and / or the Named Nurse at this
time led to a missed opportunity for social care colleagues and the Named Nurse
to discuss the case from a perspective of safeguarding scepticism and potentially
challenge the medical view that the fracture was accidently caused.
11.142. Doctor 1 has since acknowledged that he was in fact considering the possibility
of non-accidental injury (NAI) at the time, and that he should have taken a more
detailed assessment of the case and family using the Trust Child Protection
Proforma, but explains his reason for not doing so as one of time pressures.
11.143. At about 1600 hours, Doctor 8 thought he would go and see where Doctor 1 was
up to. Doctor 8 said he was feeling sorry for Doctor 1 who was a middle grade
doctor acting as locum consultant so essentially Doctor 1 was one member of the
team down. It was busy, and as it was a Friday afternoon, the Hot Week
consultant also took on any child protection cases so he was covering a number
of roles.
11.144. Doctor 13, the clinical director, was possibly meant to be available as a
supervisor for the Hot Week locum, and as stated previously Child C had been
listed as a patient of Doctor 13 as the on call consultant at the time of admission,
but he was chairing the Directorate meeting and so was unavailable during the
afternoon. Doctor 1 also said he would have liked to ask Doctor 3 to come and
talk to the parents as they were known to him but Doctor 3 was not available
either.
11.145. The Named Doctor for the Trust was not in work that day. Although the role was
not in fact being covered by Doctor 8, the Panel were unclear who was in fact
covering the position.
11.146. As a result, Doctor 1 did not therefore obtain advice from the Trust Named
Doctor or Named Nurse for Child Protection. The reason for the confusion about
who Doctor 1 should have turned to for advice could be that although the
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Hospital Trust have a copy of the WSCB Escalation Policy, for use when
professionals disagree about the management of a case, that policy did not really
apply in this situation, as the problem was that Doctor 1 did not feel reassured or
confident one way or another as to whether or not the injury was accidental. It
appeared to the Panel that both the consultants, and Doctor 1, either did not
respect, or did not understand any clear lines of management accountability or
responsibility with regard to the escalation of difficult clinical cases.
11.147. It is unclear whether or not such lines of escalation for complicated cases are
sufficiently transparent within the Trust. The Line of Accountability for
safeguarding children exists in order that front line staff are familiar with the
structure and that it informs decision making in clinical practice. This Line of
Accountability is a requirement of Section 11 of the Children Act 2004 and is
usually a requirement to be evidenced within LSCB Section 11 Audits of their
partner agencies. Within health organisations, where safeguarding children
responsibilities are delivered in addition to other core services offered, this line
of accountability is particularly important for staff in that it may differ from their
usual line management structure, encompassing the Child Protection Named and
sometimes Designated professionals as well as line managers. The structure
clarifies exactly who staff are to involve in cases such as Child C. The requirement
for this line of accountability within organisations continues within the new
Working Together 2013 guidance. In fact the Panel heard that the structure is in
place within the hospital Trust but has not yet been fully disseminated to all
staff.
11.148. Both the Named Nurse and the Designated Doctor for Child Protection were in
the hospital on the Friday afternoon but were not contacted about Child C. This
would suggest a lack of clarity in the child health medical directorate over
processes and a lack of leadership. In discussing this particular aspect of the
review, the Panel also identified within the culture and mind-set, some evidence
of possible undercurrents within the paediatric medical directorate which may
have contributed to some of the actions or in actions taken.
11.149. As a consequence of the workload pressures on Doctor 1, at 1600 hours, Doctor
8 spoke with Health Visitor 3, because the health visitor who knew the family
most was not available. Health Visitor 3 inspected the records and found no
matters of concern identified in the child protection section of the health visiting
record, no missed visits and nothing about domestic abuse within the records. It
should be noted that Child C had only received one visit from the health visiting
service by the 6th December and had never attended the well-baby clinic, so the
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health visiting service had only had one contact with the family since her birth. It
is not clear if this level of contact was considered as part of the discussion.
However, the response of “no concerns” from the health visiting service was
subsequently given some significance in supporting the decision to accept the
injury as accidental.
11.150. The explanation of the injury given to Health Visitor 3 by Doctor 8 did not make
any reference to any inconsistent or unsuitable explanation regarding the cause
of the fractured skull to Child C and therefore the explanation was not
challenged nor was child protection subsequently considered by the health
visitors.
11.151. At this point, Doctor 8 said in his reflective interview that the case had been
presented to him as an accidental injury, and that he needed to have a bit more
evidence before concluding that the parents were lying. As Doctor 1 had not had
time to do so himself, Doctor 8 then retook the history from NU and concluded
that there were no grounds to suspect that this was a non-accidental injury.
11.152. Doctor 8 said that he was really trying to accumulate other evidence to justify
undertaking the skeletal survey because the parents had given a very plausible
story. Doctor 8 did not notice that the story given to him by the parents about
how the accident had occurred was different to the story first given and in fact
the story had changed several times. This meant that in reality the parents were
not giving a very plausible story, rather they were telling a story in a very
plausible way. Doctor 8 said in his reflective interview that “it did not sound as if
they were lying…if they were lying they were very good actors” When cognitive
bias is a factor in decision making, there is often greater difficulty in seeing what
is missing, than seeing the facts which are being presented. Psychologists have
shown that two cues people use unconsciously in judging the probability of an
event are the ease with which they can imagine the relevant instances of the
event and the number or frequency of such events that they can easily
remember.
11.153. Doctor 8 has explained that another factor which influenced the decision about
whether or not to undertake a skeletal survey was the time of day. By tea time
on a Friday it would not be possible to get a skeletal survey done immediately
and that it would probably have to wait until after the weekend. If the decision
had been made that a skeletal survey had been required that morning, or even
the day before then it would have been much easier.
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11.154. The Intercollegiate Document from the Royal College of Radiologists and the
Royal College of Paediatrics and Child health states that “a skeletal survey is the
standard initial imaging method for evaluation of children where NAI is one of
the differential diagnoses. In children under the age of two where physical abuse
is suspected, a full skeletal survey should always be performed. If it is decided not
to perform a skeletal survey, the reasons for this should be detailed in the
patient’s notes”
11.155. Doctor 8 said a skeletal survey would have been undertaken if it hadn’t been
Friday afternoon, and that to now decide to undertake the survey would have
meant taking the decision to keep Child C in hospital over the weekend. It would
have been acceptable practice to keep Child C as an in-patient until all her
investigations were completed. The Intercollegiate document recognises that a
child requiring a skeletal survey may present over the weekend or at night but
states that the skeletal survey should usually be undertaken within 24 hours of
referral. If the survey could not in fact be undertaken within the timescale
recommended by guidance, it would be a matter that the local NHS
Commissioners need to address in Wigan as a matter of great urgency.
11.156. Both Doctor 1 and Doctor 8 would have been guided to undertake a skeletal
survey if they had followed the Trust policy on Bruising in Non-Mobile Children
dated 2012. Doctor 8 said that he did not think the policy was in force at the time
and Doctor 1 said that he had already made a decision that the injury was
accidental and therefore did not consider the implementing the policy.
11.157. Child C was subsequently discharged home that evening, and the opportunity to
discover the fact that someone was abusing her, and to prevent any further
abuse was missed. The fractured skull was not seen as a child protection case
and her young sibling FGU was blamed for the injury.
11.158. The Panel heard that there have been a plethora of policies and guidance that
have been produced within the Trust to the extent that there is too much
documentation to refer to and practitioners don’t always know which policy
applies. The Trust have taken steps to simplify their policies as a result of the
learning from this case.
11.159. The Panel also considered what the outcome would have been if the Trust Child
Protection Proforma had been used. This would have led to a wider gathering of
information and the case coming to the attention of the Named Nurse for Child
Protection, whose level of experience should have led to the decision making
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and management of the case being challenged, and a referral to social care. The
Panel heard that the Child Protection Proforma had not been used because the
decision was already made at the very beginning of Child C’s presentation that
this was not a non-accidental injury. The Panel also agreed that the Child
Protection Proforma should be renamed the Injury Proforma as a result of the
learning from this case.
11.160. The following Monday morning on 10th December 2012, Doctor 8 took the case
to the child protection Peer Review meeting for discussion. The Peer review
meeting has been established for 4 years and is held every Monday at 12.30. It is
chaired by Doctor 8 and usually attended by Named Nurse for Child Protection
(although neither the Named Nurse, nor was the Designated Doctor for Child
Protection attended that day), Paediatric Consultants, Registrars and Junior
Doctors. Non-accidental injuries or suspicions of non-accidental injury cases are
presented and discussed. The Peer Review meeting is a meeting to develop a
culture of learning.
11.161. It is unclear why Doctor 8 took the case to this forum, which is for child
protection cases only, unless he was unsure about the diagnosis of an accidental
injury, and he considered that the case met the criteria for the meeting.
11.162. Doctor 1 was not present at the Peer Review meeting. The Terms of Reference
for the meeting state that “Examining doctors should be present for the
discussion of their case”, which would appear to further confuse the statement
from Doctor 8 that he was not brought in to advise about the case. Again the
case was discussed at length, although the notes of the meeting do not fully
reflect the discussion as would be expected.
11.163. Recommendation 67 of the Laming Enquiry into the Death of Victoria Climbie
states “When differences of medical opinion occur in relation to the diagnosis of
possible deliberate harm to a child, a recorded discussion must take place
between the persons holding the different views. When the deliberate harm of a
child has been raised as an alternative diagnosis to a purely medical one, the
diagnosis of deliberate harm must not be rejected without full discussion and, if
necessary, obtaining a further opinion.”
11.164. Recommendation 69 states “When concerns about the deliberate harm of a child
have been raised, a record must be kept in the case notes of all discussions about
the child, including telephone conversations”. The fact that the Child C case was
presented at the Peer Review meeting was therefore further evidence that
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deliberate harm was a possible cause of her fractured skull and evidence that
therefore the management of Child C came under the authority of the Laming
Recommendations.
11.165. There were some differing opinions expressed by the paediatricians at the time
but by the end of the meeting the decision appeared to be that the injury was
accidental and that the following three factors had played a significant part in
the decision making:
The family were not known to social care
No concerns were expressed by the health visitor
Doctor 3 reporting that the family were “of very good repute and were
very nice.”
Hence the “rule of optimism” was applied.
11.166. No one thought to take into consideration that when a child is subjected to
physical abuse, there is always a first time. The fact that a child or family is not
known to social care is not a safety net or protective tool. Enquiries made to
other agencies only produced the information that the doctors wanted to hear,
“no concerns.”
11.167. Some of the information which has come to the Panel shows that since the
Serious Case Review commenced, there have been differing opinions now
expressed by the paediatricians as to what their clinical views were at the time of
the Peer Review meeting. This would further support the argument for more
detailed and formal notes to be taken at the meeting as well as highlighting the
importance of a competent chair person with the skills to ensure that everyone
at the meeting is clear about who holds which views and opinions, and that
meeting notes are accurate.
11.168. There was a further opportunity for the paediatricians to review Child C, her
injury and even reconsider a skeletal survey when she was admitted as a day
case on 11th December for her sedated auditory brainstem response, but this did
not occur.
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Following on From 6th December
(Includes Key Lines of Enquiry 1. 2. 3. 4. 5. 6. 7. 9, 10)
11.169. Child C was seen 10 times between the discharge from hospital on 7th December
and presenting in accident and emergency as a sudden death on 21st February.
11th December admission as a day case for sedated brain stem responses
20th December seen by her GP for 6-8 week check
8th January attended GP surgery for 1st immunisations
Home visit by the Hearing Support Teacher
15th January seen by Ophthalmologist at Hospital 2
17th January seen by cardiologist
30th January home visit by health visitor
4th February attended GP reduced feeding, upper respiratory tract
infection
8th February GP again with both parents as cough not improving, given
antibiotics
8th February Home visit by the Hearing Support Teacher.
11.170. The 8th February was the last time Child C was seen by any agency before her
death
11.171. Thus the impression held by the separate agencies involved with the family was
of the family were carrying on as normal and without any new concerns. The
family were continuing to engage with services and attend appointments.
11.172. During the same period of time and with the benefit of hindsight, and there were
however some underlying issues beginning to become apparent. These issues
were not identified as significant by the practitioners involved.
The visit by the health visitor planned for on 2nd January had been
forgotten about by IG
An ENT appointment for Child C on 7th January was missed
On 29th January IG attended requesting a Termination of Pregnancy
(TOP). She was 5 weeks pregnant and the records show that NU did not
know about the pregnancy
Child C did not attend for her 2nd immunisations on 5th February but was
known to be ill at the time
Another ENT appointment was missed by Child C on 5th February
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An incident with regard to transport services which occurred on 6th
February.
11.173. The Hearing Support Teacher was told by the audiology service about the head
injury to Child C on 6th December, but when reflecting on this information for the
purposes of this review, she did not feel the need to probe further with the
family at the time, and in fact did not record the matter in her notes. She did not
feel the need to be anxious or curious and believed the version of events given to
her by IG, possibly because of her positive relationship with the family up to that
date.
11.174. The IMR for the service could find no other evidence of any other discussion
between the Hearing Support Teacher and any other agency regarding the head
injury.
11.175. When the Hearing Support Teacher was told by the audiology service about the
head injury suffered by Child C, the information should have been recorded
within the case notes and brought to the attention of the team manager. At this
point there would have been an opportunity to probe the account of the injury
further with health colleagues and social care.
11.176. The Panel agreed that the Hearing Support Teacher had focused only on her area
of specialism. There was concern that the service does not appear to be alert to
any wider signs or other safeguarding issues. There is consequently a plan for the
team to undergo training. The IMR author stated that the team would benefit
greatly from training in order to equip the staff to identify matters of concern
and ask the appropriate challenging questions to parents and carers. The report
recognises the need for a cultural mind-set shift within the Hearing Support
Teacher service to be developed through a programme of training, assessment
and management oversight for the service. This would bring practitioners within
the service away from an internal culture of single agency working and go some
way to see the team members become part of the wider integrated services
available to families. It recognises the lessons learnt from the Haringey Baby
Peter Connelly case and the need for staff within the service to be assessing and
observing as well as helpful to families.
11.177. On 11th December Health Visitor 1 telephoned IG following the attendance at
Hospital 1 by Child C with the fractured skull. IG reported Child C to be well and
that the swelling had gone down. No concerns were expressed by IG to Health
82
Visitor 1. Health Visitor 1 invited IG to contact her as required and planned to see
the family on 02.01.13 at home for a 4 to 8 week contact.
11.178. The response by the health visitor to this injury is of concern. The health visitor
had only visited once since Child C was born and had not seen the family with
Child C in clinic at all. At this point she should have recognised that there was a
need for a new and more detailed assessment of the family at home, and that
her previous assessment should be reviewed. IG and NU could have been under
more stress than had been initially identified by the health visitor at the birth
visit, and this had resulted in a potentially preventable accident with a serious
injury to a five week old baby. The health visitor should have recognised that at
worst, such a serious injury could be a non-accidental one and have been
prepared to challenge the cause of the injury.
11.179. One of the reasons for providing a home visiting service by the health visitor
instead of a clinic based service is the recognition that families can easily present
very differently when they are seen away from the home. It is the view of the
author of this report that the expected response from the health visitor to this
injury should have been as follows:
First - immediately consult the GP and GP records in order to ensure that
she had all the necessary information to make an assessment of the
family. This would have given the health visitor the information she had
missed so far about the episodes of depression experienced by IG and
also be an opportunity to alert the GP to the possible causes of the injury.
Secondly, to undertake a home visit without delay. During this visit the
health visitor would need to ask very probing questions and look to speak
with the mother alone if at all possible.
Thirdly, the health visitor should have instigated a frequent pattern of
visits to the home until it was clear that no further concerns or family
stress was evident over and above her original assessment at the birth
visit. More frequent home visits may have encouraged IG to open up to
the health visitor and seek help.
The health visitor should also liaise with any other agency providing
services to the family, in this case the Hearing Support Teacher.
11.180. If the health visitors had identified a concern over the injury they could have
discussed this case at supervision or brought it to the attention of the
safeguarding children team. It would have been good practice to do so.
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11.181. The health visitors did not take this case to supervision primarily because they
did not recognise any risk from the head injury but also because they perceived
that it did not meet the threshold for supervised cases. A number of SCRs
concern cases which are not recognised as meeting supervision or safeguarding
thresholds and it becomes a training issue for those responsible for internal
policies and protocols, as well as for reflective practice sessions for front line
practitioners. The Named Nurses within Bridgewater Trust have not previously
been included in the development of mainstream policies within the Trust but
this matter has now been addressed as a result of lessons learnt from this case.
The use of carefully planned group reflective practice sessions would provide
vital support to the health visitors and assist them to assess both need and risk
within families.
11.182. The stresses within the family are further evidenced on 5th February 2013 when
IG attended hospital asking for a termination of pregnancy and said that the
father was unaware of the pregnancy.
11.183. Subsequently, Health Visitor 1 received an email from the Transport for Sick
Children service on 6th February 2013 reporting issues that had occurred when a
volunteer driver had attended the family home that day. The email indicated a
“wasted trip” for the service that day. It also said that “the man who answered
the door said he was looking after the children and that mum had been out all
night. The man also said he knew nothing about an appointment”. The Transport
for Sick Children Service also noted that the mobile number that they had for IG
was never answered.
11.184. Health Visitor 1 tried to telephone the family regarding the incident the following
day but was not successful. However, the reason for the call made by the health
visitor was only because she was worried that the transport service would be
withdrawn from the family. The incident was not recognised as a warning sign or
risk within the family by the health visitor. There is no evidence of any further
attempts by the health visiting service to contact the family in relation to this
episode. Considered together with the fractured skull, again this information
should have caused some concern or curiosity within the health visitor which
should have prompted a different response.
11.185. On 7th January when Child C was seen in the cardiology clinic she was noted to
have marked upper airways noises (stridor) which was worse when she lay on
her back, and consequently the consultant advised that she slept on her side.
This was the first time that any observation had been made about any
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respiratory distress in any of Child C’s contacts with health services. Treacher
Collins Syndrome is associated with respiratory issues. With the benefit of
hindsight, and the information from the skeletal survey on 25th February which
identified rib fractures older than four weeks, the panel considered the
possibility that the stridor may have been as a result of injuries to Child C, rather
than a medical cause. It should be noted that stridor itself is not an
acknowledged sign of non-accidental injury.
11.186. On the 8th February, Child C was taken to the GP because her cough was not
improving. The GP remembers this consultation very well and undressed Child C
to fully examine her and did not see any signs of any injury. The GP rang the
parents after evening surgery to enquire about Child C and was told that her
condition had improved. This was good practice by the GP.
11.187. It is the opinion of the Panel and the author of this report that no criticism
whatsoever should be levelled at either the GP or the consultant cardiologist, in
any suggestion that they should have been able to identify the fractured ribs.
The Health Overview Report considered the research and concluded that many
abusive fractures are not clinically obvious unless an X-ray is taken. This is
particularly true for children under the age of 2 years who will not present with
any bruising. The fractures would have been very difficult to identify on a normal
examination of Child C’s chest and are highly unlikely to be identified without an
X-ray.
11.188. The clinical practice of both the GP and cardiologist was assessed by the IMR
authors to be appropriate under the circumstances and the Panel does not
challenge their conclusions.
11.189. Later, on 21st February, NU stated that he had been told to lay Child C on her
tummy to sleep as a consequence of Child C’s stridor, but a thorough review of
all of the documentation has shown no evidence of this and that the family were
only ever given the standard safe sleeping advice and information by the health
visitors, midwives and other professionals prior to 7th January.
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Application of the SUDC Policy
(Incorporating key lines of enquiry 1. 2. 3. 4. 5. 7. 8. 9, 10)
Thursday 21st February
11.190. At 11am on Thursday 21st February, the police were quick to respond to the call
from the ambulance service reporting a four month old child had unexpectedly
stopped breathing. They arrived promptly at the hospital in less than twenty
minutes after the call but attempts at resuscitation had failed and Child C had
just been pronounced dead. Doctor 3 was present.
11.191. Police Officer 1 was introduced to Doctor 3 who told him that Child C and other
family members were affected by a genetic condition called Treacher Collins
Syndrome which caused facial deformity and potential respiratory problems.
Police Officer 1 was also told about the diagnosis of a fractured skull in
December 2012 but that Doctor 8 had examined the child and did not consider
this a case of non-accidental injury. Doctor 3 went on to say that he had never
had any safeguarding concerns in respect of Child C or her immediate family.
Doctor 3 had personal knowledge of Child C and her family and had been
involved in her care. He was therefore seen to be in a position to provide first-
hand information regarding the family. Police Officer 1 was also told that there
had been no skeletal survey undertaken at the time of the fractured skull.
11.192. The very positive comments made by Doctor 3 about the family may have caused
the police to form an early opinion rather than keeping an open mind. This
conversation would appear to have been highly significant in the initial response
by the police to manage the death of Child C as one which may have been caused
by an underlying medical condition. This may be another example of cognitive
bias affecting the decision making and actions.
11.193. By 11.30 it is recorded that initial searches of social care and police systems
showed no record indicating any cause for concern. The enquiry to social care on
6th December had not been kept on file, and at this point there had been no
formal referral to social care by the police, but Social Care Team Manager 1 was
told informally via the I-SAPP (Integrated Safeguarding and Public Protection)
team that the police had attended an incident where a child had died, and
reference was made to a genetic disorder being the cause of death.
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11.194. The I-SAPP team is a new co-located team of police and social care staff
established to improve the response times to domestic abuse and facilitate the
timely sharing of information across agencies.
11.195. The Panel queried the lack of professional challenge of the immediate medical
view about Child C’s family on behalf of the police and whether the previous
good working relationships between the individual police officer and consultants
had clouded his judgement and led to a lack of challenge.
11.196. In particular, why the fractured skull was not considered to be a significant event
by the police, to the extent that Police Officer 1 was even told that there had
been some possible discrepancies around the explanations provided by NU.
11.197. The suggestion of clouded judgement has been wholly refuted by the police IMR.
However, the initial examination of Child C by Doctor 9 in the presence of Police
Officer 1 had noted a small bruise on Child C’s face. A bruise on the face of a
non-ambulatory child should have raised suspicion, and the history known to
Doctor 9 of a previous skull fracture was an extremely significant fact that should
have been considered and given more significance.
11.198. At this point after the death, the Panel agreed that there was reluctance
between the police and SUDC doctor to re-visit the findings of the senior
clinicians involved in the initial skull fracture on 6th December in light of Child C’s
death. The Panel found that it would have been appropriate on 21st February to
now question once again what may have at the time been valid findings on 6th
December and re-examine that presentation in light of the facial bruise and
death of Child C.
11.199. Local Safeguarding Children Boards are required under Regulation 6 of the
Children Act 2004 to put in place procedures for ensuring that there is a co-
ordinated response to an unexpected child death.
11.200. Chapter 7 of Working Together 2010 requires a Rapid Response by a group of key
professionals to enquire into and evaluate unexpected child deaths, where an
unexpected death is defined as one which was not anticipated as a significant
possibility twenty four hours previously or where there was an unexpected
collapse or incident which led to the death. The Rapid Response is translated into
local policies known as the SUDC Policy.
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11.201. The SUDC policy in place at the time of the death of Child C was the Greater
Manchester Procedure for the Management of Sudden Unexpected Death in
Childhood (Rapid Response) Version 3.
11.202. Section 5.2 of this Policy requires “all unexpected child deaths to be treated
initially as a multiagency safeguarding inspection, with the immediate protection
of any siblings taking priority”. Section 5.7 of the Policy reminds practitioners
“that babies and children who have been unlawfully killed can sometimes present
without any external visible injuries”.
11.203. Section 8.2.8 of the SUDC Policy states that “from the outset of any investigation
all police staff should keep an open mind about how/why the child died…equally
police staff should be aware from the outset of any investigation that a child who
presents without any physical external or internal injury whatsoever, could still
have been unlawfully killed.”
11.204. The Panel therefore asked questions about whether agencies had responded
quickly enough to identify the risks to FGU and take appropriate steps to ensure
her safety.
11.205. The day of Child C’s death would have been the appropriate time to call a multi-
agency information gathering and strategy meeting which would be held within
48 hours. There was no immediate multi agency meeting called by the SUDC
doctor to discuss the death and identify any possible risks for FGU because the
decision had already been taken by the police that this was not a suspicious
death in light of Child C’s medical condition and the information from Doctor 3.
This was seen by the panel as a missed opportunity at the time to gather vital
information. It is unclear who is meant to take the lead on cases within the SUDC
Policy if they do not easily fall into the suspicious / non suspicious category.
11.206. The Police thought that they had made a referral to social care about the case,
but as this was just a conversation within the I-SAPP team this was viewed as an
informal communication by social care, and was not acted upon as a referral.
11.207. In section 5.13.of the SUDC Policy it states “following a home visit by the Senior
Investigating Officer (SIO) and SUDC Paediatrician within 24 hours of the death,
the SIO, SUDC Paediatrician, GP, health visitor or school nurse, and children’s
social care should review whether there is any additional information that could
raise concerns about the possibility of abuse or neglect having contributed to the
child’s death”.
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11.208. A home visit was made that day by Police Officer 1 and Doctor 9. The time of this
visit is not recorded as would be expected. Although the home was untidy, there
was nothing to indicate any concerns at the address in relation to safeguarding.
It would appear that the case was being treated entirely as a non-suspicious
death.
11.209. At some point early after the death, Doctor 9 removed and retained the clinical
notes for Child C from the hospital, which was not agreed within the SUDC policy,
and which both prevented Doctor 3 from recording the presence of a small
bruise on Child C’s forehead at the time, and prevented others from having
access to the history within the records. The inability to complete the recording
does not appear to be significant in the immediate management of the case.
Doctor 9 did, however, then have the opportunity to study the records and in
particular the injury on the 6th December and consider this injury and the
inconsistent stories in light of the death. If he had done so, it is likely that the
case would have been re classified and concerns raised. The removal of the
records was also problematic in that none of the other clinicians, including the
safeguarding team, subsequently had access to the notes for the purpose of
reviewing the case and obtaining information.
11.210. A decision was subsequently made at 15.00 hours between Police Officer 1 and
Doctor 9 to hold a standard post mortem on Child C, as opposed to a forensic
post mortem. The police records also confirm that the CID would conduct a SUDC
special procedure death investigation into Child C, but took no further action
that day. It would appear that there was no longer any investigative mind-set
being applied to the case.
11.211. The Panel considered why social care did not challenge the lack of an early multi-
agency meeting as per the policy. Information had come to social care about the
death of Child C via an informal communication to a social worker co-located
within the Police Protection Division. The initial details known to social care were
limited and an agency search on the names and addresses revealed no trace of
the family. Reference was made within the social care IMR but not substantiated
within the police report about a communication from the police to social care of
the belief that a genetic condition was the cause of death, even though there
was no medical diagnosis given to the cause of death at the time.
11.212. The Panel heard that in addition to an understanding that this was a non-
suspicious death, key staff within social care were also very diverted by another
particularly serious case which had come to light at the same time as Child C.
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11.213. Furthermore, children’s social care did not have on record the previous enquiry
to their service in December about the skull fracture, so did not make any
connection with this previous serious injury.
11.214. At this point, no one took action to share the news about an unexpected death
with the community health services, or GP, who may have had pertinent
information on the family, and who are also expected under the SUDC Policy to
provide immediate support to a bereaved family if the family are not known to
social care.
11.215. No one in social care took any action to implement any further the social care
responsibilities as defined within the SUDC Policy, or challenge the actions of the
police and SUDC response so far. The local authority social care computer system
is different to that used by the Hearing Support Teacher. If thorough searches of
other agencies had been made, it would have been revealed that the Hearing
Support Teacher had had considerable contact with the family. As a result, the
search failed to identify any vital and detailed history or information about the
family that could have been known to the HST.
11.216. At this point, the social care workers should have challenged the lack of a multi-
agency meeting as required within the SUDC Policy, and they themselves
initiated a strategy meeting. This would have given the opportunity to challenge
both the account of the fractured skull in December and the assumption that
Child C’s death had been as a result of a medical disorder, and fully consider the
risks to FGU. The SUDC Policy states “if there are concerns about surviving
children in the household local procedures for managing child protection
enquiries should be followed. The recommended Sequence of Events following
an unexpected death is shown as a flow chart in section 7 of the Policy. However,
there are no timescales against some of the actions either within the policy or on
the flow chart, which is an important omission and may have contributed to the
result that there was no multi agency case discussion meeting being held on 21st
February for Child C. Thus a second opportunity to call the strategy meeting was
missed. Another Serious Case Review recently in the Greater Manchester Area
published in December 2012 has also identified serious implications for the
timely sharing of information in relation to the safeguarding of related children
under the SUDC Policy, and the potential for long periods of time in which
information is not available. The review of the SUDC Policy initiated as a result of
that SCR was not completed at the time of Child C’s death.
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11.217. Appendix H of the SUDC Policy states that “if the family is not known (to social
care) then the primary support to the family will be given by health workers and
the police”. When the Panel were asked which practitioners in this case provided
support to the family in the days after the death of Child C, it became clear that
this aspect of the Policy had been subject to oversight. The SUDC Policy is not
sufficiently explicit as to which health agency or practitioner is expected to
provide immediate bereavement support, as this is expected to be agreed within
a local implementation protocol by the WSCB.
Friday 22nd February
11.218. No actions were taken on Friday 22nd February apart from a telephone call to the
health visiting team telling them about the death of Child C. it is not recorded
which agency made the call.
11.219. At some point after hearing about the death of Child C, the GP went out to visit
the family, which was good practice.
23rd and 24th February
11.220. No actions were taken over the weekend. FGU was at home with her parents and
the plan was to wait until the hospital post mortem would be held on Monday
25th February. It was agreed between Police Officer 1 and Doctor 9 that once the
post mortem process was completed, Doctor 9 would compile a case report and
convene a multi-agency partners meeting in accordance with the SUDC policy. It
is clear that at this point, there were no thoughts that FGU could possibly be
unsafe; otherwise different actions would have been agreed and taken.
11.221. Still no challenge was made to the police and Doctor 9 about the response taken
by them for this case.
Monday 25th February
11.222. Doctor 9 did ring Health Visitor 1 at some point on Monday 25th February to ask
if advice had been given by the health visiting service to place Child C in the
prone position to sleep, as NU had reported that this advice had been given to
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the family. Health Visitor 1 was able to confirm that only standard safe sleeping
advice had been given to the family by the health visiting service. In fact the
advice to place Child C on her side to sleep had been given by the consultant
cardiologist.
11.223. On Monday 25th February, four days after the death of Child C, and at 17.45
hours, when the standard post mortem was about to commence, the initial
review of the CT scan from 6th December and skeletal survey examination of
Child C revealed 2 separate skull fractures showing on the CT scan and several
bilateral rib fractures of various ages. The findings were reported to the Coroner
who halted the post mortem and ordered a forensic post mortem examination to
be conducted. This was scheduled for Wednesday 27th February.
11.224. At 18.25 hours that day, the first discussion within the police took place
concerning the possibility of potential safeguarding issues relating to Child C as a
result of the injuries found on the x-ray.
11.225. There was recognition during that discussion that consideration may have to be
given to removing FGU from the family home if the injuries to Child C were non
accidental in origin. However, their initial multi-agency enquiries had not
identified any prior safeguarding concerns and the police felt that more
information was necessary to inform the safeguarding decision making process.
Once again there was no recognition that when a child is physically abused, there
always has to be a first time.
11.226. A decision was therefore taken that there would be no immediate police action
to remove FGU from the parents until the results of the forensic post mortem is
known.
11.227. The Panel considered why this decision was taken, when Child C clearly had
serious injuries of some severity which had occurred at different dates. The
police representative on the panel was of the opinion that the information given
to them about the injuries was not properly digested as the significant
information that it was. The decision whether or not to remove a child using
emergency police powers at this stage is often made by very senior officers who
are not working within the safeguarding arena. These senior officers would have
been greatly influenced by the humanitarian consideration of the level of distress
experienced by the parents who had just had a baby die, and would therefore
not want to over react and remove another child unless absolutely necessary.
The decision was also likely to have been influenced by the additional factor of
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Child C having Treacher Collins’s Syndrome, and the accompanying uncertainty
about whether or not this syndrome could have resulted in Child C’s bones being
more susceptible to fracture.
11.228. As stated above, on 25th February, at the post mortem, Doctor 10 had reviewed
the earlier December CT scan and found a second, older skull fracture. The
skeletal survey also showed further fractures to ribs, all consistent with non-
accidental injury (NAI). This information was shared with Doctor 14 who in turn
told Doctor 9 in a telephone call at about 17.30 hours. Doctor 14 is also alleged
to have said in this conversation that the police were aware of the news and that
they were taking action.
11.229. The police account concurs with the above information about the injuries and
then says that the initial decision was made by the police that there would be no
immediate police action to remove FGU.
11.230. The social care chronology only indicates that information had been received
from the police that morning as a result of a call made by the children’s social
care team manager to Police Officer 4 who told her that no concerns had been
identified with regard to the death of Child C. There are no further discussions
recorded about Child C by children’s social care that day.
11.231. The Panel took the view that there should have been a multi-agency strategy
meeting on 25th February, but as the information came to the police in the
evening, this meeting would have realistically been expected to be convened
early on 26th February.
Tuesday 26th February
11.232. A further indication of concern about the seriousness of Child C’s Injuries should
have come on 26th February, if the account by Doctor 9 of his telephoning the
Senior Investigating Officer is considered. Doctor 9 recalls that he “was surprised
that no action had been taken and says it was unacceptable that that the sibling
wasn’t protected”. However, this call is not corroborated within the multi-agency
chronology. It took until around 15.00 hours before a referral of circumstances
was submitted by the police to children’s social care with regard to convening a
safeguarding meeting with respect of FGU. There is no record of Doctor 9
contacting children’s social care directly himself in the meantime to share the
concerns that he had that morning. It is also unclear why the referral to
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children’s social care was not completed by the police either the previous
evening or first thing that day.
11.233. The children’s social care report, states that further information was shared
between Police Officer 4 and Team Manager 3 informally following a strategy
meeting on an unrelated child. This is not detailed within the multi-agency
chronology. During this conversation the team manager was told about the two
injuries which had been identified from the CT scan taken in December and the
skeletal survey results leading to the decision to undertake the forensic post
mortem. She was also told about the fractured skull in December and that the
parents had given two different explanations at the time but that the injury was
deemed to be accidental.
11.234. It is regrettable with hindsight, that although children’s social care advised the
police that a safeguarding plan was now needed with respect to FGU, they did
not request or initiate an immediate strategy meeting. This would have given the
opportunity for key safeguarding professionals to objectively question the
decisions made so far and look again at the injury in December from a position of
respectful curiosity. In addition, depending upon local service thresholds,
concerns may have been held within universal services about the family which
did not meet the threshold for a formal referral. This was a lost opportunity to
gather important information. The learning from this case about the timing and
membership of strategy meetings should be incorporated into a revision of the
SUDC policy so that the same opportunities are not lost in other cases in the
future.
11.235. As previously stated, it was not until 15.15 hours on 26th February hours that the
police formally made a referral of circumstances to children’s social care. A joint
visit was then agreed for later the same day.
11.236. At 19.30 hours the joint visit was undertaken with both Police Officer 3 CID and
Social Care Team Manager 1 to the family home to share information and put
safeguarding measures in place for FGU. NU and IG were not given the details of
the injuries to Child C. but told that the post mortem would review the new
information. FFG was at the home and the three adults signed an agreement that
IG and NU would have no unsupervised contact with FGU.
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Wednesday 27th February
11.237. The forensic post mortem was commenced on 27th February and at around 12.00
hours Doctor 9 rang Social Care Team Manager 1 to tell her that the post
mortem was part way through and confirmed that there were 9 rib fractures of
different ages along with two skull fractures and bruising. It was good practice on
behalf of Doctor 9, to share the information immediately rather than waiting
until the end of the post mortem. This led to a reclassification of the case as a
homicide investigation and a strategy meeting was held at 16.30 hours that day.
The only representatives at the strategy meeting were social care, police and
Doctor 9 as there was now an urgent need to hold the meeting. Both NU and IG
were arrested during a joint home visit at 19.00 hours and FGU was made the
subject of a Police Protection Order and placed with foster parents, six days after
the death of Child C.
11.238. The social care IMR acknowledges that the service missed opportunities to have
convened strategy meetings on 21st, 25th and 26th February, and recognises the
value of the information sharing and subsequent impact on decision making that
would have occurred.
11.239. The Panel considered whether the decision to make a working agreement with
the grandmother for two days was sufficient to protect FGU. It was only
apparent much later, and after FGU had been placed in foster care that FFG had
had care of Child C on 19th February and therefore should not have been
considered as part of the safety arrangements made for FGU. This information
would have come to light within a strategy meeting if it had taken place in the
immediate time after Child C’s death.
11.240. It remains unclear as to why the serious information from the skeletal survey and
review of the CT scan on 25th February did not lead the police to a decision to
remove FGU immediately to a place of safety. This was the point at which the
statutory threshold for social care involvement had been met, although the
referral was not made. The information about the injuries from the forensic post
mortem on 27th February which finally prompted this action to remove FGU does
not appear to contribute much in the way of new information. Both the police
and social care IMRs respond to this point in that they were considering the
“degree of risk” and “the need to balance any risk of physical harm with the need
to ensure that her best interests were met in all aspects of her welfare.”
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11.241. Once the need to consider safeguarding FGU was recognised, the subsequent
forty eight hours was a long time until the appropriate action had been taken,
and both the police and social care reports have reflected upon their decision
making at the time. It was the considered view of the Panel that on other
occasions, this same decision to leave a child with her family would have been
an unsafe one and that the practitioners in the Child C case did not have enough
evidence at the time to be confident that it was not an unsafe one for FGU.
11.242. All along the team manager and service manager should not have accepted the
police view that there were no safeguarding concerns and no suspicious
circumstances around the death of Child C. They should have taken a more
proactive role and contacted the SUDC paediatrician to hear first-hand about the
medical information when no strategy meeting was convened. The Panel have
recognised that the SCR has identified key lessons concerning leadership in all of
the agencies.
11.243. The Panel discussed the hypothesis that the family where not the typical
stereotype of those identified within the NSPCC study of Serious Case Reviews in
children under one, where domestic abuse, mental ill health and substance
misuse were factors in 94 of 130 cases looked at. Lack of the above known
contributory factors in Child C’s family may have influenced the early assessment
that there were no suspicious circumstances around Child C’s death. However, in
truth, the known contributory factors were not fully searched for at all about
Child C’s family. There was no contact made with either of the GP practices for
the parents which could have held an abundance of information on factors such
as substance misuse, any previous abuse or violence by NU, mental ill health for
either parent and would have certainly revealed information about the
depression which IG suffered from.
11.244. The matter of informal information sharing by the police to children’s social care
at times when formal referrals should have been made became quite
problematic in the days following the death of Child C and appears to have
inhibited children’s social care from responding appropriately and timely after
Child C’s death. Eventually the formal referral was made by the social care team
manager to her own agency. The informal information sharing also prevented
the social workers from fully questioning the little information that was given to
them in a fragmented fashion and the implications of that information then got
lost.
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11.245. An external consultant radiologist has since reviewed the CT scan to see if the
second fractured skull should have been identified on the 6th December at the
time of the injury. The report that has subsequently been produced has indicated
that a specialist radiologist would not have missed the second fracture to the
skull on the CT scan, but that a generalist radiologist may have missed it. This has
implications for the Trust with regard to identifying non accidental injury in
children and the reporting of scans. Furthermore, the Panel were advised that a
skeletal survey would have identified the second fracture to the skull on 6th
December if it had been undertaken.
11.246. The second skull fracture was an old fracture and pre dated 6th December. There
has been some discussion and suggesting that this fracture could have been as a
result of a birth related injury and would therefore be of no concern. However,
the Designated Doctor for Child Protection has reviewed the birth history and is
of the opinion that Child C’s delivery by caesarean section with no post-delivery
complications makes the possibility of a birth induced fracture less likely.
Multi Agency Interface within Safeguarding Processes
(Includes key lines of enquiry 1. 3. 4. 5. 7. 8. 9)
11.247. It is interesting to note that lesser injuries than those of Child C suffered by
children in Wigan have frequently led to multi agency meetings. There are clear
benefits to multi agency collective decision making within safeguarding
processes, but for Child C this did not happen when it should or could have taken
place. The Panel agreed that the unilateral decision making by the paediatricians
at the admission on 6th December prevented this procedure from being put into
action for Child C, although if collective decision making had gone ahead, it could
have helped key individuals to recognise safeguarding issues. This placed the
paediatricians in an unsafe position of power with regard to the safety and
welfare of Child C in December, and again it was a significant factor in the
decision making and the failure of key people to think and act in the investigative
mind set as required by the SUDC Policy. The danger with unilateral decision
making is always that a case may not be recognised as a child needing
protection.
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11.248. The paediatricians need to see the social workers as a resource and Named
Nurses as system leaders and an additional resource available for decision
making and advice both from within the hospital Trust, and to an extent also the
community Trust. The paediatricians need to understand more fully the benefits
of joint assessment and decision making. In order for this to happen the Panel
agreed that there is a need for mandatory attendance at dedicated multi agency
training.
11.249. In looking at the local policies and practice for the purpose of this review, it
would appear that references to multi agency working in practice often only
includes police, social care and the hospital or SUDC doctor. It is not uncommon
elsewhere also for references to be made as to having complied with the
requirement for the inclusion of “health” within multi agency discussions or
meetings, when in fact only one representative from a health organisation or
specialism is in attendance. Health organisations provide vastly different and
diverse services to families and children, and it is not possible for any one health
professional to have all of the health knowledge, assessments and information
on a child or family.
11.250. The Panel agreed that the Named Nurse within the hospital Trust has not so far
had her expertise and potential as a child protection resource fully recognised,
and found that this was one of the lessons to be learnt in this case. It was of
some surprise that she was not brought into case discussions and her opinion
sought both at the 6th December admission and after the death of Child C. She
would have also been able to liaise with the community Trust Named Nurses
when the injury occurred to Child C in December, again increasing the possibility
of appropriate respectful challenge and sceptical objectivity which would provide
both the practitioners and children with an additional safety net. There is a need
to review the position and status of the Named Nurses by the respective
organisations.
11.251. The Panel considered in detail whether or not the decisions taken to safeguard
FGU after the death of Child C would have been different if a multi-agency
strategy meeting had taken place immediately after Child C’s death. This meeting
would have included all of the professionals involved with the family, along with
members of the respective agency safeguarding teams who would have the
ability to provide more sceptical challenge and objectivity. It was decided that
the presence of the Named Nurses from the hospital and community Trusts, and
the involvement of the SUDC consultant would have put the history of the
previous fractured skull under scrutiny again including the decision making at
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that time. The Panel agreed that a decision would have likely been taken at that
strategy meeting to remove FGU from her parents care and most likely placed
with foster carers. Instead she was left for 6 days with her parents and wider
family, one or more of whom is now known to have inflicted serious injuries on
Child C.
11.252. The GP practice held important information about the family of Child C, in
particular the stress which IG was under, but did not share this information. The
Panel queried if there is sufficient GP representation on the WSCB in order for
the lessons identified in this case to be embedded into arrangements and
contracts with the GPs locally.
11.253. The health visitors did not always receive the expected written notifications from
the hospital. The post of health visitor liaison had been previously
decommissioned. The Designated Doctor holds the view that this post was an
important additional resource within the hospital safeguarding team, although
the Panel heard differing opinions about this matter. Recommendation 90 of the
Laming Enquiry into the Death of Victoria Climbie states “Liaison between
hospitals and community health services plays an important part in protecting
children from deliberate harm.” The Bridgwater IMR uncovered echoes from the
Laming Enquiry with regard to notifications to the health visiting service and this
system should be subject to a review to ensure that it is suitably robust.
11.254. There is no evidence that culture or ethnicity had an impact on the family’s
response to the children’s disability. There is also no evidence that issues of
culture or ethnicity affected service provision.
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12. Individual Agency Reports and Recommendations
12.1 The following actions were taken as part of the Rapid Appraisal:
Social Care
1. The Duty Service now regard all checks made with them by Accident and Emergency
regarding safeguarding to be a contact and record the telephone call as such. Team
managers review all contacts and will be required to form a view on the content of
the information being provided and requested by the referrer. This will ensure that
there is an opportunity to consider the seriousness of any injury to a child by
Children’s Social Care.
2. Children's social care now records any enquiry about whether a child is known to
Wigan Council's children's services from the hospital as a contact. This is to
ensure that all requests for information are a matter of record and are subject to
social work oversight.
Wrightington, Wigan and Leigh NHS Trust
1. A letter from the chair of the LSCB about bruises in infants and non-mobile
children has been circulated to health staff working in child health, paediatrics,
accident and emergency and midwifery.
2. The non-mobile policy has been updated to include children up to one year.
3. All children under 1 year attending accident and emergency with bruises will be
seen by paediatric middle grade doctors as well as accident and emergency staff.
All children under 2 years with a fracture will be seen by an accident and
emergency consultant, if not then referred to paediatric middle grade.
4. A letter was sent out to the paediatric consultants by the medical director with
regard to the assessment and management of vulnerable children
5. Information and leaflets on bruising in non-mobile children has been recirculated
to all practitioners and a working group was established to review the
safeguarding policy on bruising
6. Training was provided for paediatric staff with regard to protocols for bruising
and head injuries.
7. All paediatric head CT scans are now seen and reported by two radiologists and
advice is taken from Hospital 3 specialist radiologists if they are in doubt about
non accidental injury.
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Bridgewater Community Trust
1. NSPCC Bruising leaflet circulated to all front line practitioners working across
ALW division of Bridgewater with a letter from the chair of WSCB
2. The Safeguarding Team have attended the working group to review WSCB policy
on bruising/injuries in children
3. An email was sent on 12th July 2013 to all health visitors and school nurses
regarding the importance of keeping an up to date chronology with records and
updating family composition at each contact
4. An email was sent on 10th July 2013 to all health visitors and school nurses to
instruct then to date stamp and sign all correspondence received
5. The Systm1 working party was informed of the need to ensure all templates
devised support the recording of family composition and the regular review of
this information in an email sent 2nd July 2013
6. A group was convened in the 0-19 universal pathway to review and improve GP
and HV/SN communication and liaison this includes GP representation
Joint letter from the Designated Nurse and Named Doctor
1. A letter from the Designated Nurse and Named Doctor dated 15th March was sent out
to all staff working with children along with a leaflet on bruising on children. This
highlighted the importance of timely and appropriate response to any injuries in non-
mobile children.
GPs
1. A letter was sent to all GPs by the Named Doctor on 11th April. This letter
requested a high level of suspicion regarding bruising and possible non accidental
injuries in non-mobile children and referred the readers to where they could
obtain further information and advice
2. Named GP has attended the working group to review WSCB policy on
bruising/injuries in children
3. A group was convened in the 0-19 universal pathway to review and improve GP
and HV/SN communication and liaison this includes GP representation
Individual Management Reviews
Social Care
12.2 Wigan Council Children’s Social Care produced a chronology and IMR. The
timeframe for the report was 21st February – 7th March 2013.The IMR was co-
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authored by two Service Managers in order to ensure sufficient independence
and objectivity. Neither author was experienced in IMR writing. The report was
countersigned by the Director of Children’s Services Wigan BC.
12.3 Whilst there is much good critical analysis within the report, it would have
benefitted from the addition of some pertinent information and analysis of the
implementation of the social care responsibilities defined SUDC Policy. There
were some delays in the final submission of the report going to the Panel. Key
learning from the IMR includes:
12.4 - The need to fully understand and implement the SUDC procedures; being pro-
active in ensuring that all available information is considered on a multi-agency
basis and in a timely way. The initial assumption that Child C’s death was a direct
result of her genetic condition delayed an investigation into the actual cause and
appears to have influenced the use of the SUDC procedures.
12.5 - Children’s Duty Officers are expected to record as a formal ‘Contact’ any
enquiry to Social Care from a doctor or hospital regarding a child. A Team
Manager then decides whether further information is required and whether the
Contact should progress to referral and assessment.
The recommendations from the report are:
1 To ensure that Children’s Social Care is a key contributor to decisions made and plans implemented when there is a sudden unexpected death of a child or infant.
2 To improve practice in analysis and risk management by developing an
understanding of the role of hypothesis.
3 To improve the recording of enquiries by hospitals to Children’s Social Care so
that appropriate safeguarding decisions can be made.
4 For Social Care to support other professionals with their responsibility to make a formal referral if there are child protection concerns.
5 To promote on going good practice by ensuring access to effective supervision and support for staff when dealing with child deaths and in cases where previous practice is under scrutiny.
6 To raise awareness of the role and function of the targeted disability team within
Social Care; Gateway and amongst other agencies.
Police
12.6 Greater Manchester Police produced a chronology and IMR. The timeframe for
the report was 21st February – 7th March 2013.
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The Author is a Review Investigator for the Force.
The report was countersigned by the Force Review Officer GMP.
12.7 There is a good degree of critical analysis within the report and the first draft
submitted to the Panel was of a high standard. Supplementary information was
also submitted to the panel to assist in the SCR.
Key learning from the IMR includes:
12.8 - During the course of a safeguarding investigation, where a potential risk to a
sibling(s) is identified it is best practice to formally notify partner agencies of the
nature of that risk at the earliest opportunity in order to facilitate multi agency
discussion and decision making around the appropriate safeguarding response
to the risk.
12.9 The SUDC paediatrician and the police officer investigating the death were
informed about the previous skull fracture and the parental explanation for it,
but the existence of the fracture, the parental explanation for it and the
consultant’s acceptance of the parental explanation were not challenged at the
time. The fracture was not considered significant until additional skull fractures
were found which pre-dated the original injury.
12.10 The SCR includes concerns that the SUDC investigation may not have applied a
sufficiently robust investigative mind-set during the initial investigation and as a
consequence failed to challenge both the parental explanation for it and the
consultant’s acceptance of the injury as accidental despite the fact that it was
present in such a young and immobile child.
12.13 The IMR author has discussed the issues raised above with the GMP trainers
responsible for delivering SUDC training to GMP staff. The concepts of
‘maintaining an investigative mind-set’ and ‘challenging medical opinion in SUDC
investigations where appropriate’ are both key elements of the existing SUDC
training package. (Training is based on two SUDC case study scenarios.) It is the
intention to provide the Training Unit with an anonymised summary of the
relevant aspects of this case for inclusion within the current training material to
highlight and reinforce the importance of these concepts to GMP staff attending
future training sessions.
The recommendations from the report are:
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1. Officers involved in safeguarding investigations should be reminded that where
an investigation identifies potential risk to a sibling(s) it is best practice to
formally refer the facts to partner agencies at the earliest opportunity. (To
facilitate multi agency discussion and decision making around the
implementation of an appropriate level of safeguarding measures in respect of
the sibling(s).
2. The Force Training Unit delivers a SUDC training programme which already
addresses the concepts of “maintaining an investigative mind-set” and
“challenging the opinions of medical professionals in SUDC investigations.” The
IMR author/SCR panel member will consult with the training unit and provide an
anonymised summary of this case for inclusion in the current training package to
reinforce these concepts in all future training deliveries.
Specialist Sensory Education Team (SSET)
12.14 The SSET submitted a chronology and IMR. The timeframe for the report was 13th
January 2011 – 27th February 2013.
The report was written by the Early Intervention and Prevention Service
Manager, who was inexperienced in writing an IMR.
The report was countersigned by the Director of Children’s Services Wigan BC.
12.15 The report looked at the work of the Hearing Support Team, which is part of the
SSET service. This service is one of four Borough wide Early Intervention and
Prevention Services.
12.16 The report acknowledges that the service has struggled to recognise the
safeguarding role that it should have. The report lacks in pertinent detail, both
as a result of poor record keeping and the level of critical analysis applied
despite the submission of several versions. The recommendations were revised
following the production of the draft Overview report, and if robustly applied
will go some way to changing the culture within the service. It is clear from the
IMR that the service have not had in place adequate safeguarding practice or
management oversight at the front line.
Key lessons from the IMR are:
12.15 The SCR has heightened the awareness of the safeguarding context in key areas of work within the SSET and other borough wide specialist teams.
- There is a need to review the case note/recording and file management system
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within the SSET team.
- Safeguarding training for all staff must be delivered, with an emphasis on
wider observations and partnership collaboration especially where young
children/families may have unmet needs and linking to the CAF process.
- The SSET eligibility criteria for support levels matrix utilised to assess the
allocation of hours does not include safeguarding in detail. Reference to the
CAF (Early Help) assessment will be included.
- The support, supervision and management oversight of cases especially
around safeguarding requires auditing.
The recommendations from the report are:
1. The service will ensure that this review is shared within the EIP for all teams to
action the lessons learnt. The service manager shall also cascade final SCR
recommendations to all teams within the EIP.
2. The service will ensure that there is an amendment of the case file system of
recording interventions for young people so that as well as specialist information
being recorded, wider familial, safeguarding, and partnership interventions are
recorded. This will be audited to ensure compliance.
3. The service will ensure that all staff revisit safeguarding 3 refresher training. This will
include a reminder of their responsibilities in relation to CAF and safeguarding
procedures and links to GM SCB website.
4. The service will ensure that the support and supervision and teacher appraisal
templates are revisited and updated for all staff working with young people so that
safeguarding and child protection has a clearer area of focus and has management
oversight.
5. The service will ensure that the team has representation at the EIP safeguarding
champions network so that the team sees safeguarding as a team responsibility and
benefits from elements of the WSCB section 11 safeguarding matrix as well as
contributing to the regular audits.
6. The service will ensure that managers conduct a 6 monthly audit within the team
around case files and support and supervision/appraisals to ensure the holistic needs
of families and considered and appropriate information sharing and communication
takes place between professionals working with families, especially in relation to
those children who do not meet threshold for social care.
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7. To review and revise the Thresholds of Need document in line with the requirements
of Working Together 2013 and to ensure all stakeholders have a better
understanding of appropriate services to children and their families in Wigan.
Wrightington, Wigan and Leigh NHS Foundation Trust (WWL)
12.16 WWL submitted a chronology, IMR and additional information to the Panel.
The report was written by the Named Nurse for Child Protection.
The report was countersigned by the Executive Lead for Safeguarding Children
The timeframe included within the IMR is from May 2007 – March 2013.
12.17 This report was a long and complex one to write. The author was inexperienced
in writing IMRs and yet produced a report to a good standard. The critical
analysis of the medical decision making and actions is very good and the author
was able to overcome some difficult obstacles in getting the information that
was needed. The report was very helpful in gaining an understanding of the
decision making and actions of the paediatricians, which is essential to the
lessons learnt in this case. In particular, the reflective interview with one of the
paediatricians was an excellent piece of work.
12.18 The decision to incorporate and integrate the midwifery services into the body of
the report did not assist the learning for the Serious Case Review. The Named
Nurse is not a qualified midwife. Although the Named Midwife was consulted in
the writing of the report, there still exists gaps with regard to information about
the service model and important critical analysis of the midwifery service is
absent. As a result the organisation has missed an opportunity to identify
lessons for the midwifery service and implement learning as a direct result of
this case. There were requests at Panel meetings for more information from the
midwifery service which were unheeded. The midwifery service should have
been the subject of a separate IMR or a dedicated chapter within the WWL
report.
The recommendations are:
1 Review information sharing procedures between health and social care.
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2 To review and streamline all WWL Child Protection policies, procedures and
guidelines. To have one overarching Trust wide Child Protection Policy with a set
of procedures.
3 Review the pre-printed existing accident and emergency paperwork used upon
admission and ensure it is completed to a high standard.
4 To review and embed the Bruising in Immobile Children Policy (2012) into
practice.
5 Training to all frontline staff on the importance of record keeping and
documentation.
6 Review the existing Child Protection Safeguarding Children Medical Proforma
(2011).
7 Review the current peer review supervision systems for frontline staff within
WWL.
8 Provision of a training package on Physical injuries focusing on Immobile children
who present at accident and emergency with serious accidental and non-
accidental injuries.
9 Strengthening Lines of accountability and responsibility in child protection within
WWL with regards to safeguarding / child protection from the Executive lead to
the frontline staff.
10 A review of the SUDCI procedures.
11 Review the current process of how X rays and CT scans are reported.
12 Review the use of the Safeguarding proforma and contacts with Social care in
non-mobile children presenting with accidental or non-accidental injury.
SUDC
12.19 The SUDC Rapid Response Team submitted a chronology and IMR. The
timeframe for the report was 21st – 27th February 2013.
The report was written by the SUDC lead and consultant paediatrician
The report was countersigned by the Chief Officer for Wigan Borough Clinical
Commissioning Group
The report author recognises in a statement within the report that as a Peer of
the SUDC Paediatrician involved in the case, this may have impaired objectivity.
There is a good level of detail and critical analysis within the report.
The key lessons in the report are:
12.20 - To learn the need to recognise injuries in death that are highly suspicious of
NAI.
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- To confirm that there is need for early recognition of these injuries to plan for
early forensic examination.
- To learn there is no need to wait for Post Mortem examination to safeguard
children.
- To learn that at the time there was not a clear pathway as to what to do if
skeletal survey raised safeguarding concerns.
- To learn that there could be clearer guidance about who leads cases where
there is an evolving level of suspicion.
- To confirm that sharing information between agencies allows for the most
successful safeguarding for children.
The recommendations are:
1. SUDC Doctors need to recognise the significant of previous injuries even if
they have previously been accepted as accidental. The importance of
previous skull fractures and facial bruising in non-ambulatory children must
be recognised as significant.
2. SUDC doctors to keep a decision Log, documenting telephone calls during the
rapid response process if concerns are raised, what conclusions are drawn
and what the action plan is.
3. SUDC Protocol should include who is lead for cases when new information
comes to light and the case shifts from non-suspicious to suspicious.
4 . SUDC Protocol should have an agreed pathway for information sharing if
skeletal survey shows suspicious fractures, including need for multiagency
discussion.
Wigan Borough Clinical Commissioning Group GP Report
12.21 Wigan Borough Clinical Commissioning Group submitted a chronology and IMR.
The report was written by the Named Doctor for Safeguarding children.
The report was countersigned by the Chief Officer for Wigan Borough Clinical
Commissioning Group
The timeframe included within the IMR is from April 2010 to March 2013. The
report is well written with a good degree of critical analysis and information.
12.22 The key lessons within the report are:
- The Practice keeps records which are satisfactory but could be improved by the
inclusion in each case of a plan of action following each consultation.
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- The case shows a need to review communication systems between GPs and
Health Visitors
- The case highlights the need to be alert to the causes of bruising/injuries in
non-mobile children. There should be a review of the training provided to be
certain that this is fit for purpose.
- Safeguarding training within the Practice is satisfactory but could be improved
by consideration of the Intercollegiate Document on appropriate levels for GPs,
Practice Nurses and receptionists.
12.23 The recommendations within the report are:
1. Raise awareness of bruising in non-mobile infants.
2. Define the information sharing requirements between HVs, School
Nurses and GPs and recommend its implication.
3. General Practitioners and their staff to be trained to appropriate
level as recommended by the Intercollegiate Document.
Bridgewater Community Healthcare Trust
12.24 Bridgewater submitted a chronology and IMR.
The report was countersigned by the Executive Nurse / Director of Governance
Bridgewater Community Healthcare Trust.
12.25 The original author of the report was a Named Nurse experienced in IMR writing.
However, the report was not at the required standard and it was recognised that
it needed a major re-write. The second submission was co-authored by a
different Named Nurse / Team Leader and a Specialist Practitioner for
Safeguarding Supervision. A very detailed and comprehensive report written to a
very high standard and containing high levels of critical analysis was submitted
within the allowed timeframe. This was the first time either author had
undertaken writing an IMR, and they completed the task in just two weeks.
12.26 The key lessons from the case are:
- Where there exists disability and multiple health issues, practitioners do not
always acknowledge that the family may still require an increased level of
support.
- Practitioners do not view CAF as a way of coordinating multidisciplinary
services within health.
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- The Health Visitor Caseload Dependency Tool does not exactly mirror Wigan
Safeguarding Children Board Threshold of Need and that this has caused
confusion.
- Health Visitors are failing to clearly document when they have reassessed need
on the Health Visitor Caseload Dependency Tool
- The chronology of significant events form is not being used consistently across
disciplines
- There is inconsistent document control in relation to versions and archiving of
historical policies and procedures.
- The Safeguarding Team are not always consulted when Services create or
review their policies and procedures.
- Documentation does not always support the comprehensive recording of
family history and composition.
- The follow up of accident and emergency attendances in relation to life
threatening injury, where safeguarding concerns have not been identified, is
inadequate.
- The procedures for injuries to children who are non-mobile is not robust.
- The process for the collection and distribution of accident and emergency
liaison notifications is not robust.
- Although health visiting staff reported that they were confident to respectfully
challenge colleagues, they failed to exercise professional curiosity.
- Staff are unsure of who undertake key Statutory Safeguarding roles across the
health economy.
- There is not a standardised system across health visiting to inform General
Practitioners of pertinent information regarding their clients.
- The speech and language service do not notify the health visiting service when
clients opt in following referral and when clients do not attend appointments.
12.27 The recommendations within the report are:
1. A review of the use of CAF by health practitioners needs to be undertaken.
2. Use the re-launch of the revised CAF documentation by the Local Authority as
an opportunity to raise awareness of CAF’s use as a multidisciplinary tool.
3. A review of the antenatal home visiting clinical procedure as set out in:
Clinical procedures for the health visiting service record keeping, core contacts
and additional targeted health reviews and assessments, needs to be
undertaken.
4. The Health Visitor Caseload Dependency Tool needs to mirror the WSCB
Threshold of Need.
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5. Practitioners need to be reminded of the importance of keeping a
consistent, comprehensive and up to date Chronology of Significant Events
and the consequences of not doing so.
6. Policies, procedures, guidance and key service documents need to have a
clear version control system and need to be archived and be accessible once
they have expired.
7. The System One templates need to be revised with the knowledge of the
need for a comprehensive family composition and for this information to be
updated and revised on a regular basis.
8. A review of the process for receiving and distribution of Accident and
Emergency liaison slips needs to be undertaken.
9. A review of the 0-19’s years Core Health Service Guidelines for Health Visiting
and School Health Service Actions on Receipt of Notification Forms from
Accident and Emergency, Minor Injuries and Walk in Centres needs to be
undertaken.
10. A review of the ‘no access’ policy needs to be undertaken in respect of ‘no
access’ visits where there are no known concerns.
11. The Safeguarding Team to continue to contribute to Wigan Safeguarding
Children Board development of a multiagency bruising and injury protocol
for non-mobile children, and ensure that it is cascaded to practitioners.
12. Practitioners need to be updated on who undertakes the Statutory
Safeguarding roles across the health economy.
13. The General Practitioner Practices need to be reminded of the names of the
link health visitor for their Practice.
14. The Speech and Language Service to inform the Universal Caseload Holder of
when a child has opted in to and failed to attend an appointment.
15. The Bridgewater Safeguarding Team to devise a ‘One Bridgewater’ approach
to the management of Serious Case Review.
Health Overview Report
12.28 The Designated Doctor produced a combined health chronology. The HOR was
co-authored by the Designated Doctor and Designated Nurse. The report was
countersigned by the Chief Officer for Wigan Borough Clinical Commissioning
Group.
12.29 The Designated Doctor and Designated Nurse were both very committed and
helpful to the SCR process and ensured that essential additional information
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came to the Overview Author without delay. The Designated Professionals also
spent considerable time providing support to the inexperienced Named
professionals. The first draft of the HOR contained further detail not found
elsewhere which informed the Review. The final version of the report was
appropriately concise, identifying key themes and commissioning issues. The
report is to a high standard for both content and analysis.
12.30 The recommendations are:
1. WBCCG to Review the Service Specification for Midwifery with commissioners and
a review of the health visitor and midwifery pathways to be undertaken.
2. To scope out how CAF and Pre-CAF can be embedded into contracts to ensure
family’s needs are addressed early.
3. The WSCB has set up a task and finish group of multiagency professionals to
review and make recommendations on workforce response to injuries.
4. WWLFT share cost improvement plans (CIP) with commissioners in a format
which allows both the commissioner and provider to understand the implications
on safety and quality.
5. WBCCG seek assurance from WWLFT that front line staff at WWLFT understand
lines of accountability in relation to safeguarding and how to escalate concerns.
6. Rapid Response protocol would benefit from timescales being added to section 7
Recommended Sequence of Events.
7. A review of the commissioning arrangements, governance and lines of
accountability for the Rapid Response Service.
8. The WBCCG via Quality Support and Safeguard (QSS) to seek evidence from
providers that audits have been undertaken to ensure single agency
recommendations have improved practice.
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13. Conclusions and Recommendations
13.1 Child C presented as an unexpected death aged 4 months. She was known to
have an inherited condition called Treacher Collins’s Syndrome which is
associated with breathing problems. She had an older sibling and father with the
condition, and at the time of writing this report, the cause of death is unknown.
13.2 One of the challenges in undertaking a Serious Case Review is the public
interpretation of a report, which is required from the outset to identify areas of
learning and improvement. In many situations, this does not mean that practice
was found to be significantly problematic, rather a matter of seeking to raise
standards to optimum practice. Every child, individual and family is individual,
different and complex; this is what enriches our society. Every case that public
service professionals deal with is unique and always different once the casework
commences and real engagement with the family occurs.
13.3 This was not a case where safeguarding concerns had been previously identified.
Without fail, the family presented as loving and co-operative to the services
involved. However, in any case on non-accidental injury, there always has to be
a first time when a child is abused.
13.4 From the start of the pregnancy with sibling FGU to the death of Child C, the
family were only ever in receipt of universal health services, along with some
specialist hearing and language services.
13.5 Professionals did not view Child C to have a disability or be a child in need
because they thought that the needs were being addressed by the parents.
13.6 This case does show some similarities to the findings in an SCR on Child B in
Bexley completed in 2012 and published in 2013, which found a failure of
universal services to consider non accidental injury when a child presents with
bruising, and assumptions that parents had come to terms with their child’s
disability.
13.7 There are many lessons to be learnt from this case about improving inter agency
communication and liaison. This is an on-going challenge identified in most if not
all SCRs, however, for the family of Child C, there has been some prolonged “silo
working” by the midwives, health visitors and GPs in Wigan that needs to be
addressed as a matter of urgency.
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13.8 In order for the lessons from this case to be suitably embedded into practice,
some of the recommendations require that the WSCB receives on-going
assurance, usually via case file audit.
Recommendations from the Overview Report are interwoven in bold text throughout
the conclusion section:
1. WSCB need to be regularly consistently assured of appropriate liaison and
communication between midwives health visitors and GPs for families who do not
meet the child protection threshold. This assurance should include families with
children with disabilities and abnormalities. It should also include cases where
mothers are prescribed anti-depressants and there are one or more additional
factors present which are likely to cause family stress.
2. WSCB need to be assured that the threshold for ante natal visits, support and
liaison between health services is appropriate in light of the findings of this case
3. WSCB need to be assured that the midwifery services in Wigan are being delivered
according to the Service Specification and national standards and targets. In future,
the service must produce a dedicated separate report for any Serious Case Review
or Multi agency Management Review and not incorporate this into a combined
Trust report.
4. WSCB need to be regularly and consistently assured that GPs and practice staff
have training and identified responsibilities about which information they need to
share with health visitors. This information must include significant matters which
come to their attention which may affect parenting capacity.
5. WSCB need to be assured that front line practitioners within all services which
constitute the Specialist Sensory Education Team, recognise and are exercising
their duty to proactively safeguard and promote the welfare of children.
6. WSCB need to be assured, including receiving regular case file audit, that the
Corporate Caseload model of health visiting service used in Wigan enables the
early identification of:
families and children who meet the requirement for further assessment via the
Common Assessment Framework or other formal assessment.
events and injuries which require a reassessment of the level of service offered.
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Cases which should be raised at Supervision, but which are below the threshold
for inclusion in mandatory Supervision processes.
7. The WSCB need to receive regular assurance that the providers of universal health
services and Early Intervention and Support Services are sufficiently trained and
competent in identifying and responding in a timely way when levels of
vulnerability within families are increasing.
8. The process whereby health visitors receive written notification and liaison from
the hospital trust should be subject to a review by the health commissioners to
ensure that it is suitably robust.
9. Mandatory training needs to be provided to all practitioners regarding children
with disabilities and the impact of disability on families. The training should also
include the lessons learnt from recent Serious Case Reviews regarding the
misleading presentations of parents where practitioners have thought that families
where co-operative and presented well, the effects of cognitive bias. The
important need for professional curiosity and respectful enquiry along with an
objective analysis of significant events.
10. The WSCB needs to be assured that the Common Assessment Framework is
sufficiently embedded in practice across the Borough, and that front line
practitioners are trained to identify factors which will impact on parenting
capacity.
13.9 The response by the hospital to the attendance by Child C on 6th December with
a fractured skull was not satisfactory. The paediatricians exhibited a lack of
“respectful uncertainty.” Lord Laming used this phrase to remind practitioners to
keep an open mind about possible child protection issues. This is even more
important for disabled children who are known to be more vulnerable to abuse.
There is currently another SCR underway in Wigan in which there are concerns
about a hospital’s response to safeguarding a child. Whilst a recent external audit
of the Trust has confirmed that recommendations from the Laming Enquiry are
included within the written documents and processes for the hospital, it is clear
from this review and interviews with staff that the recommendations are not
informing or sufficiently embedded into clinical practice. The findings within this
Review indicate that the unsatisfactory systems followed by the paediatricians for
the Child C case are not unusual practice.
13.10 Whilst the cause of death remains unascertained, and may always do so, the
tragic death of Child C cannot be found to be a preventable one. However, it is
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possible that had the paediatricians responded differently on 6th December, that
the subsequent injuries and suffering known to have occurred before Child C
died, could have been prevented or curtailed. This was a missed opportunity.
Recommendations from the Overview Report:
11. WSCB need to be assured that the safeguarding and child protection processes
within the paediatric medical directorate of Hospital 1 are satisfactory. This should
be provided to the WSCB via an urgent Paediatric Medical Peer Review of the
medical paediatric systems and practices used within the Trust which relate to the
safeguarding and protection of children. The Peer Review needs to be sufficiently
independent of any local professional relationships which may inhibit objectivity.
In light of the findings from a recent external audit, the Peer Review must not be a
paper exercise. The Peer Review must look at clinical practice and leadership
within the paediatric medical directorate. Key outcomes of the Review must be:
Professional scepticism and respectful challenge becomes embedded in routine
medical practice from the very beginning of a presentation.
Recognition within routine practice that parents and carers do abuse babies
and children and will seek to mislead professionals.
A heightened awareness within the paediatric medical team to maintain a
focus on the child as paramount, despite the distraction of the parent’s
presentation
12. WSCB need to receive assurance from Hospital 1 via case audit evidence that the
changes made with regard to the Injury Proforma has resulted in non-accidental
injury being included in the differential diagnosis when children present with
injuries.
13. WSCB need to be assured that the recommendations from Lord Laming’s Enquiry
into the Death of Victoria Climbie are embedded into practice within the hospital
Trust. In particular, this must include the responsible Consultant reviewing the
child and the safeguarding decision making before discharge in cases where NAI is
a differential diagnosis.
14. WSCB need to be assured that there is appropriate practice consistent with
national practice standards with regard to the use of skeletal surveys in children.
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15. WSCB should ensure that regular mandatory multi agency safeguarding children
training for social workers and hospital paediatricians and other hospital staff is
established. The training should include an objective of achieving a better
understanding of each other’s roles and competencies.
16. WSCB should seek assurance that there are sufficient processes in place when
children present to the hospital Trust and non-accidental injury is considered by
the paediatricians or doctors to be a possibility (at any time), for appropriate cases
to be discussed with children’s social care and or the Named Nurse.
17. WSCB should seek assurance via their Section 11 audit arrangements that
satisfactory arrangements are in place within their partner organisations.
13.11 On Thursday 21st February, when Child C arrived at hospital, the professionals
involved quickly moved away from having an open and investigative mind set.
The IMRs reflect some important lessons identified within this case with regard
to the interpretation and implementation of the SUDC Policy. However, there
was a similar theme with regard to the investigative mind set identified in the
SCR in respect of Child V in Manchester in 2012, which also came under the
same SUDC Policy.
13.12 FGU was left with her wider family for six days after the death of Child C. there is
now an investigation looking into who has inflicted serious injuries on Child C.
Some of those injuries were not visible or thought to be significant at post
mortem. If a multi-agency strategy meeting including all of the professionals
working with the family had been held immediately after Child C’s death,
including safeguarding professionals from those services, the history of the
previous fractured skull would have come under more scrutiny, with the
outcome that FGU would have been removed to a safer placement sooner.
With this in mind, the following recommendation is made.
18. The SUDC Policy should be amended as a result of the learning from this case. As a
minimum:
To include specific timescales against actions within the policy and
flowcharts.
To ensure that information is shared and multi-agency meetings are called
within forty eight hours of an unexpected child death. Attendance at such
meetings should include the Named Nurses for the hospital and
community Trusts or their deputies as well as front line staff. At this
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meeting, the focus should also include the welfare of any other siblings and
the identification of any risk.
To include robust arrangements for which service and practitioners are to
provide immediate support to families following unexpected child deaths.
To ensure that social care undertake a more widespread search of contacts
that the family have had with other agencies following a death
To include social care in the initial decision making between Police and the
SUDC doctor as to whether a case is to be managed as suspicious or non-
suspicious.
13.13 In December 2013, the Finding of Fact Judgement with regard to FG was
made. This Judgement supported the conclusions of the Overview Report,
and in particular commented about the following:
On 6th December when Child C presented with a fractured skull, the lack of
referral to police or social services resulted in no real analysis of how a major
skull fracture could be caused by a two year old with a low velocity fall.
There is no indication that a skeletal survey carried out on 6th December
would have detected any other injury to Child C, however, further enquiries
would have achieved a greater protection for FGU. At this point the
perpetrator of a serious non accidental injury would have understood that
even serious abuse can go undetected.
The decision not to initiate further investigations at this time had been
wrong. The argument put to the court by one very experienced paediatrician
with regard to his interpretation of the 2008 Intercollegiate Report by the
Royal College of Paediatricians and Child Health and the Royal College of
Radiology, Standards for Radiological Investigation of Suspected Non
Accidental Injury and guidance within to always perform a full skeletal survey
when physical abuse is “suspected” in children under the age of two years
was tested. It was argued that the guidance did not apply in the case of Child
C because abuse was not “suspected”; the rationale being that the injury was
at least as likely to be accidental as non-accidental. This argument from the
paediatrician led to a finding from the Judge, who determined that the
doctors had rightly considered the injury to be non-accidental ie they had in
fact “suspected” non-accidental injury and therefore the guidance did apply.
As a result the judge directed the Local Authority to draw to the attention of
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the Royal Colleges the detail contained within the judgement with a view to
consideration being given to an amendment of the wording of the guidance
so as to prevent any similar misinterpretation by doctors occurring again.
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14. Bibliography
Bexley Safeguarding Children Board. (2013). The Overview Report of the Serious Case
Review in Respect of Child B. 2012. www.bexleylscb.org.uk
Brandon, M. Bailey, S. Belderson, P. Gardner, R. Sidebotham, P. Dodsworth, J. Warren, C.
Black, J. (2009). Understanding Serious Case Reviews and their Impact. Department for
Children Schools and Families. London.
Brandon, M. Bailey, S. Belderson, P. (2010) Serious Case Reviews: A two year analysis of
child protection database notifications 2007 – 2009. Department for Education.
Brandon, M. Sidebotham, P. Bailey, S. Belderson, P. Hawley, C. Ellis, C. Megson, M.
(2012). New learning from serious case reviews: a two year report for 2009 – 2011 Centre
for Research on the Child and Family in the School of Social Work and Psychology, University
of East Anglia.
Cardie, C. Feature Selection for Case-Based Learning: A Cognitive Bias Approach Cornell
University www.cs.cornell.edu.home.cardie. Papers
Cardiff Child Protection Systematic Reviews www.core-info.cardiff.ac.uk accessed 16th May
2013.
Department for Children Schools and Families. (2009). Safeguarding disabled children:
practice guidance. www.teachernet.gov.uk/publications
Department for Education. (2010). Working Together to Safeguard Children A guide to
inter-agency working to safeguard and promote the welfare of children
www.education.gov.uk
Department for Education. (2012) The Common Assessment Framework Process.
www.education.gov.uk
Department for Education. (Updated March 2013) Statutory Guidance on Making
Arrangements to Safeguard and Promote the Welfare of Children Under Section 11 of the
Children Act 2004 www.education.gov.uk accessed 20th August 2013
Department for Education. (March 2013). Working Together to Safeguard Children . A
guide to inter-agency working to safeguard and promote the welfare of children
www.education.gov.uk
120
Department of Health. (2000). The Framework for the Assessment of Children in Need and
their Families. London. HMSO.
Department of Health. ( 2009). Healthy Child Programme: Pregnancy and the First 5 Years
of Life www.dh.gov.uk/publications
Department of Health. (2011). Health Visitor Implementation Plan 2011 – 2015. Call to
Action.
Department of Health. (undated) Health Visiting and Midwifery Partnership – pathway for
pregnancy and early weeks.
General Medical Council (2012) Protecting Children and Young People. The responsibilities
of all doctors. Section 90
Laming. H. (2003) The Victoria Climbie Inquiry. HMSO. London.
Manchester LSCB. (2012). Serious Case Review in respect of Child V.
Munro. E. (2011). The Munro Review of Child Protection. Department for Education.
London.
National Institute for Clinical Excellence. (June 2010). Clinical guideline CG 62 Routine Care
for the healthy pregnant woman www.nice.org.uk
National Institute for Clinical Excellence. (2009 updated 2013). When to suspect child
maltreatment www.nice.org.uk
Ofsted. (2011). Ages of Concern: Learning lessons from Serious Case Reviews.
www.ofsted.gov.uk
Ofsted. ( 2012). Protecting disabled children: thematic inspection www.ofsted.gov.uk
Reichman, N.E. Corman, H. Noonan, K. (2008). Impact of child disability on the family. Child
Health Journal.
Royal College of Paediatrics and Child Health. (2010). Safeguarding children and young
people: roles and competencies for health care staff. www.rcpch.ac.uk
Royal College of Paediatrics and Child Health. (2011). Facing the Future: A Review of
Paediatric Services www.rcph.ac.uk
121
Royal College of Paediatrics and Child Health. (April 2012). Consultant Delivered Care. An
evaluation of new ways of working in Paediatrics www.meetingthechallenge.co.uk
Royal College of Paediatrics and Child Health. ( 2012). Peer Review in Safeguarding
www.rcpch.ac.uk accessed May 2013
Royal College of Paediatrics and Child Health. (2013). Child Protection Companion. London.
Royal College of Radiologists and Royal College of Paediatrics and Child Health. (2008).
Standards for Radiological Investigations of Non-accidental Injury.
www.rcr.ac.uk/docs/radiology accessed May 16 2013.
Social Science Podcast published January 4 2013. Daniel Kahneman on Bias
www.socialsciencespace.com
The Children Act 1989. Section 17
The Psychology of Intelligence www.cia.gov/library 2007 (accessed august 2013)
Wigan Safeguarding Children Board (2009). Serious Case Review Child B.
www.wiganlscb.com
www.patient.co.uk/doctor/Treacher-Collins’Syndrome accessed 21st May 2013
www.treachercollins.co.uk accessed 21st May 2013