Learning Review

1. Learning Review Sutton LSCB learning from Serious Case Reviews 2015

2. Statutory and non-statutory case reviews The Working Together (2015) statutory guidance sets out that LSCBs should have a local Learning and Improvement Framework (published on the LSCB website) so that: • Reviews are conducted regularly, not only on cases which meet statutory criteria, but also on other cases which can provide useful insights into the way organisations are working together to safeguard and protect the welfare of children and that this learning is actively shared with relevant agencies; • Reviews look at what happened in a case, and why, and what action will be taken to learn from the review findings; • Action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and • There is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of Serious Case Reviews (SCRs) with the public. SCRs are usually published on the website of the LSCB for a year; NSPCC holds all published SCR on its online national SCR repository http://www.nspcc.org.uk/preventing-abuse/child-protection-system/england/serious-case-reviews/

3. Serious Case Review A notifiable incident is an incident involving the care of a child which meets any of the following criteria: • a child has died (including cases of suspected suicide), and abuse or neglect is known or suspected; • a child has been seriously harmed and abuse or neglect is known or suspected; • a looked after child has died (including cases where abuse or neglect is not known or suspected); or • a child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected). The local authority must report any incident that meets the above criteria to Ofsted and the relevant LSCB promptly, and within five working days of becoming aware that the incident has occurred. The final decision to undertake a SCR is with the Independent LSCB Chair.

4. SCR standards A good quality SCR has the following features: • A sharp focus on what caused something to happen and how it can be prevented from happening again. • A concise account of critical points in the management of a case (rather than a lengthy chronology of undifferentiated events). • A detailed analysis of what went wrong and why, including individual errors and system failures. • Clear learning points and recommendations that are addressed to named people or organisations locally and nationally, including adult services where appropriate. • Measures should be included to follow up and see whether these recommendations have been accepted and implemented. • A focus on what the lessons should be for the services concerned, rather than giving a blow-by-blow account of what happened to a child. • Highlights relevant failings and good practice and policy at all levels, not just those at the lower levels.

5. Case Study 1 • Woman admitted to delivery suite by ambulance in advanced labour on their wedding day. • Unbooked and no Antenatal care. Around 32 weeks gestation. • English not first language (moved to UK from Lithuania approx 1yr ago). • Husband disclosed wife’s alcohol misuse. • Mother disclosed had 1yr old Son living in Lithuania. • Possible dysmorphic features noted by Paediatrician. • Not registered with GP. • Follow up with Paediatric outpatients arranged.

6. Case study 1 cont: • Baby taken to the Emergency Dept on 3 occasions by mother as baby unsettled and diagnosed with reflux. • Did not attend x1 Outpatient appt. (Foetal Alcohol Syndrome diagnosed). • Baby placed on Child Protection Plan under category of neglect. • Baby died aged 6 months in Lithuania.

7. Emerging lessons: • Referral to CSC not made for 3 days. • Discharge Planning meeting held but minutes not placed in hospital notes. • Inadequate information sharing between hospital midwives, community midwives and Health Visitor. • Interpreter not accessed in hospital. • Not registered with GP for 8 weeks.

8. Case Study 2 • Current national SCR, yet to be published. Background: Young child died while in the care of her father

9. Emerging Themes: • Significant amounts of potentially hidden DV • Maternal and Paternal mental health difficulties • Volatile and aggressive behaviour exhibited by father. • Poor communication between professionals at times. • Records keeping was less than adequate

10. Emerging themes cont: • Information sharing was poor at times. • There was a lack of professional curiosity . This was also evident in another of our SCR Child E. (This has been published and is available on the Sutton LSCB website or the NSPCC website) • Professionals were intimidated by the process imposed on them by the legal department and the media publicity it was attracting. • The question is should professionals have felt so paralysed?

11. Case Study 3 – national SCR • Baby was found unresponsive by mother and later confirmed dead • Mother and baby had fallen asleep on a sofa and cause of death was probable overlaying. • Ambulance crew noticed the smell of alcohol on mother and called police.

12. Background • Mother suffered chronic neglect as a child • Mother entered local authority care in mid childhood where she remained until discharge at age 18. • As a looked after child had disrupted placements • Mother had significant alcohol and drug misuse as a teenager and into twenties • The lack of identification of the father and the hopes and fears that he might represent to mother. • No professional at any stage had a true understanding of the relationship between the mother and father

13. Emerging Lessons • Professionals demonstrating anxiety about challenging service users who inhibit professional recognition of safeguarding • Professionals failing to explore patterns of behaviour such as missed appointments and recognising potential risks • The relative invisibility of men or professionals being embarrassed to ask • Obstacles to information sharing, which exist beyond the willingness of professionals to share information.

14. Emerging Lessons • The importance of recognising adverse childhood experiences such as chronic neglect and the inclination of individuals to deny • Workload may impact recognition of safeguarding within normal activity • Failing to recognise the impact of domestic abuse and violence on a child

15. National Serious Case Reviews • Below is just a few of the high profile SCR’s for young children completed within England. • Baby P – High profile case • Hamzah Khan 4 year old starved to death - Bradford • Daniel Pelka – 4 year old beaten and starved to death in Coventry.

16. Baby Peter • 17 months old when he died at the hands of his mothers boyfriend and his brother. He was found to be suffering from more than fifty injuries. • Suffered significant long standing abuse over an 8 month period despite being subject to a child protection plan - including a broken back, gashes to his head, a fractured shinbone, ripped ear, blackened fingers and toes and the horrific list goes on. • His family were seen 60 times by professionals • Professionals were unaware who was actually residing within the home. There was at the time of Baby P’s death the mothers boyfriend, his brother and his three children, his girlfriend who was 15 years old, three of Baby P’s siblings, three large dogs and a couple of snakes. • At professional contacts the other occupants would disappear • Professionals fail to spot injuries to baby P’s face and hands after he is deliberately smeared with chocolate to hide them.

17. Emerging Lessons: - A failure to challenge – SW were reluctant to press Baby P’s mother over the inability to explain his injuries. - A failure to appreciate risk – reported that despite repeated injuries to the child ‘little significance was given to the possibility that a small baby had been injured deliberately’ - Failed to investigate the new boyfriend - Failure of professionals to attend child protection meetings - A failure to trust instinct – lack of trust in using professional judgement , in the knowledge that they may be mistaken.

18. Hamzah Khan • Hamzah died on approx Dec 2009 but his body was not discovered until Sept 2011, he had been hidden for a number of years within the home. • He had been severely neglected and starved to death. • He was four years old when he died. • He was one of 8 siblings, five of which were still residing within the home at the time of his death • There was huge amounts of DV within the home and in the latter years alcohol misuse that severely affected his mothers ability to parent. • There had always been a long history of non engagement with health and other professionals and poor school attendance for the children. • Mother wanted all services to believe that the children were living outside Bradford with relatives. • Hamzah was an invisible child • SCR reported that professionals needed help to ‘Think Family’ and to see adult behaviour in terms of implications for their children – Do we think this happening?

19. Daniel Pelka • Daniel died following a head injured inflicted by his mother and stepfather in March 2012. • For a period of at least six months prior to this he was starved, assaulted, neglected and abused. His older sister was expected to explain away his injuries as accidental. • There was a heavy presence of DV with all three relationships that mother was known to have had, the police were called out a recorded 27 times. • History of misuse of alcohol consumption by mother • Daniel once started school began to scavenge for food in bins and lunch boxes. • Daniel often came to school with bruising and unexplained marks on him. These injuries were not recorded – no referral was made • School attendance was poor and EWO were involved • In February 2012 was seen by a community paediatrician, low weight was linked to a likely medical condition. The potential for emotional abuse or neglect as possible causes were not considered. The paediatrician was unaware of the physical injuries that the school had witnessed.

20. . • There was a deeper analysis completed of how services were operating ordered on the back of the SCR findings. - why information was not effectively recorded - Why information was not shared - Why four separate assessments by social care failed to identify the risks to the child before he was murdered.

21. Themes • Communication • Written Documentation • Professional Curiosity • Information Sharing

22. Communication • Do not be afraid of challenging parents who may be disguising compliance or diluting concerns • Challenge about failing to attend appointments or repeated cancelling so not accessing services • Have a healthy professional curiosity- ask about relationships and where individuals fit into children’s lives • Ensure that other professionals understand what your concerns are- SBAR

23. Record Keeping/Documentation • There was evidence of poor record keeping across all agencies in our local serious case reviews and this is a national trend. • Records were found to be inaccurate and not completed in a timely way – Why would this be a problem? • There was no recorded evidence of the voice of the child – Why do we need the voices of such a young child? • Poor internal and external communication – ie; poor communication between midwife and health visitor, and social worker to social worker, teacher to teacher…. • No completion of growth charts within the health records – Why do you think it is important to have such information?

24. Record Keeping/Documentation cont… • In own agency Notes • Share information you have with other agencies • Document what you have shared

25. Professional Curiosity • An evaluative and questioning approach • The ability to spot flaws and inconsistencies in information • Be less willing to take things at face-value • Be less willing to extend trust towards others. • Have an eye for detail in important too, combined with the inclination to look more conceptually and in a broader way at problems. • Spot connections and patterns in disparate information which others may not necessarily see.

26. Information Sharing • Update training includes requirements for making accurate and timely referrals to appropriate agencies. • Handover process within the hospital more robust. (Handover checklists). • Guidance on arranging and managing discharge planning meetings issued. • Improved and more robust handover to Community Midwives. (Hospital notes and checklist). • Pathway included in guideline for communication with Health Visitor. • Link Midwife on Postnatal Ward in place.

27. Information Sharing • Internally/externally ensure that the seven golden rules of information sharing are adhered to alongside local protocols. • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419628/Information_sharing_advice_safeguarding_practitioners.pdf • Check information you have within your organisation on the family – this means you have to look at the wider picture not just your own entries. • Look for Missed appointments – persistent theme in SCR

28. Seven Golden Rules • The Data Protection Agency is not a barrier to sharing information • Be honest with the ‘subject’ from the outset • Seek advice if in doubt • Duty to share if in public interest (but consider consent before sharing) • Consider safety & well-being of subject • Only share if necessary, proportionate, relevant, accurate, timely & secure • Record your decision & what you share

29. Cont… • Attendances/ access of other services within your organisation and outside your organisation – Persistent theme to often use other hospitals and services to try to ensure there is no joining up of the concerns. • Ensure that any sharing of information is documented in a timely way in line with your organisations guidelines and your professional body.

30. Information Sharing • Same agency- do you have joined up systems – In Daniel Pelka case it was identified that there were no family records kept therefore transfer of information to school nursing was difficult • Within health: Primary Care Acute Maternity Secondary Care • Children’s Social Care- CAF • Education- Primary/ Secondary Schools – When Daniel was arriving in school with bruises these were seen by different professionals and not recorded therefore nobody had noticed a pattern emerging.

31. Non- mobile Babies and Children • Local Procedures • Bruising and injuries in non-mobile children • Take cases to supervision • LSCB Protocol is being developed – during this interim period it is important that all bruising in non mobile children is discussed with your manager ensuring that all concerns have been considered. If concerns remain then a referral into MASH will be required.

32. Workshop • How does the information we have discussed impact on your service? • How will this change your practice? • Key learning individually that you will take away?

33. Legislation

34. Contact details • Tracey Bogalski – Named Nurse Safeguarding Children Sutton – t.bogalski@nhs.net (secure) 0203 668 1882 07884473284 • Sarah Harman – Named Nurse for Safeguarding Epsom and St Helier Hospital – sarahharman@nhs.net (secure) 0208 296 3377 07975 232152 • Carolyn Payne – Named Midwife for Safeguarding Epsom and St Helier Hospital – Carolyn.Payne@esth.nh.uk 07717320144 • Camilla Webster, LSCB Business manager 0208 770 4879 Camilla.webster@sutton.gov.uk