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Lessons from Recent Serious Case Reviews

Lessons from Recent Serious Case Reviews

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Lessons from Recent Serious Case Reviews

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  1. Lessons from Recent Serious Case Reviews Amanda Boodhoo Consultant / Designated Nurse Safeguarding Children, NHS Surrey

  2. Introduction This presentation covers 4 x Serious Case Reviews, 3 x Case Reviews and 1 x Single Agency Review, which were carried out between 2009 and 2012.

  3. Child I S.C.R Gender: Female Age: 8 months Summary: In December 2009 , child I died while in her mother’s care. Child I was eight months old at the time of her death. Her mother had recently turned 18. Child I is from a family of white UK origin.

  4. Background Information • Maternal grandmother suffered serious illness during child I‘s mother’s teenager years. • Child I’s mother had significant difficulties in her behaviour and schooling. • Child I’s mother’s chaotic behaviour led to her putting herself at risk. • Mother’s relationship with her partner(s) was marked by violence and domestic abuse. • Serious domestic conflict continued in the family home. • Child I’s mother was hospitalised following two reported overdoses. • Number of agencies were involved with child I’s mother but to little effect.

  5. Background Information cont.. • Visits by health professionals and social care but not initially aware of domestic abuse in relationship with partner. • Mother reluctant to engage in services. • MARAC in other Local Authority. • One occasion Child I taken to grandmother’s by police. • Mother and child I housed independently in September 2009. First time lived alone. • Domestic abuse continued and agreement that there would be ICPC if further incident. • Mother met a new partner and this relationship was also violent. • Decision to hold ICPC

  6. Key Issues Identified • Professionals missed a number of significant opportunities to safeguard and promote the welfare of both child I and her mother. • Lack of co-operation by mother and her family highlighted need for good staff supervision. • The efforts of agencies were not well coordinated. • Mother was not recognised as child in need in her own right which would have assisted a coordinated approach. • Number of services recognised her vulnerability as a pregnant teenager but these were poorly coordinated. • Need for pre-birth assessment undertaken early and structure of child protection plan. • Ineffective use of written agreements with mother. • Most significant shortcoming in work in the case were due to failures to process and act on information that had been shared between agencies. • Significant of incidents of domestic abuse were not appreciated by professionals. • Need to focus on impact of domestic abuse on the child.

  7. Key Issues Identified cont… • MARAC need to communicate with staff dealing with case. • Need to improve collaboration between social care and mental heath services. • Guidance should be issued to make explicit that professionals working with pregnant under 18 year olds should offer CAF assessment and lead professional. • Use of CP procedures for 16 and 17 year olds subject to domestic abuse. • SSCB procedures to be effectively disseminated. • Managers equipped to assess and manage risk in child protection work were domestic abuse is a concern. • Guidance should be issued to make explicit that professionals working with pregnant under 18 year olds should offer CAF assessment and lead professional. • Use of CP procedures for 16 and 17 year olds subject to domestic abuse. • SSCB procedures to be effectively disseminated. • Managers equipped to assess and manage risk in child protection work were domestic abuse is a concern.

  8. Child L S.C.R Gender: Female Age: 6 Years old Summary: In 2010 Child L was admitted to hospital having sustained injuries, allegedly inflicted by mother’s partner during an argument between him and mother. At the time of the incident Child L’s older half-sister and her child were staying at the address.

  9. Background Information • Child L was born to white British parents who were not married to each other. • Child L’s mother had three older children who were living with her husband out of area • Child L’s parent’s relationship was always troubled and when Child L was very young there were a number of disputes about custody and contact arrangements. These disputes involved a range of agencies including the police, courts and social work services. • Despite the difficulties between the parents the care provided to Child L was good and generally there were no concerns about development. Child L’s mother however developed serious health problems when Child L was quite young. This meant that she was housebound for a period and that she needed assistance from some professionals in order to maintain her independence and capacity to care for Child L.

  10. Background Information cont… • Relations between Child L’s parents continued to be poor and Child L’s mother moved for a period to live out of area taking Child L with her. Child L’s school attendance throughout this period was not good which may have been because of health problems but may have also been affected by the parent’s disputes and mother’s disability. • Child L’s parents separated and mother began a relationship with Partner 1 who moved into live with Child L and mother. By this time the only professionals in contact with the family were school staff and the GP. There was no direct contact by any agency with her new partner. • In 2010 there was an incident at the family home that involved Child L, mother and mother’s partner. The details of the event are not totally clear but Child L sustained serious injuries which were inflicted by Partner 1. He has pleaded guilty to two counts of grievous bodily harm. At the time of the incident Child L’s half-sister and her child were resident in the house. There was no contact by a Surrey agency with this child. There was routine contact by primary care agencies out of area but nothing relevant to this review.

  11. Key Issues Identified 1. Marital discord and agency intervention to safeguard child L there was significant evidence of marital discord between Child L’s parents. The attempts by both parents to involve professionals in their marital conflict affected how agencies responded to both parents. The focus of most agency intervention was in responding to the parents and in defusing their mutual antagonisms. The court was involved in this process but Cafcass had minimal involvement and there was very little mediation between the parents. Child L’s needs, wishes and feelings were not apparent and there is little evidence that any professionals considered Child L separately from the parents; Child L was in effect ‘the invisible child’. 2. Mother’s disability and its impact on Child L Child L’s mother became increasingly disabled during the period of the review. At no time was there an assessment by any of the services of the impact of mother’s disability on her capacity to care for Child L. It is possible that mother was able to meet fully all of Child L’s needs but it is unclear how professionals knew that, as there is no evidence that the question was asked. It is also probable that Child L’s poor school attendance was in part due to mother’s ill health. Given the allegations of domestic abuse it is unfortunate that this assessment was not undertaken as it is possible that mother’s dependency on Child L’s father for assistance in caring for Child L may have affected her ability to separate fully from him. It must be noted however that this view is not supported by Child L’s mother who denies he provided much direct care for Child L.

  12. Key Issues Identified cont…. 3. School attendance and its relevance in safeguarding Child L Child L’s school attendance was poor throughout the period of the review. Retrospective review does not provide clear reasons for Child L’s absences from school. They did quickly identify it as a problem and provided support via the home school link worker. They also attempted to have regular meetings to discuss it with the parents which rapidly involved them in the marital conflicts of the parents. At this point they did not consider via the Common Assessment Framework (CAF) involving other agencies. This was certainly a family where there were a wide range of known difficulties; disability, poor child health and marital conflict; and it is probable there were other factors that were less apparent. 4. Agency interaction with male partners in the household Child L’s father may have been treated differently because he was identified as a perpetrator of domestic abuse (his perspective). There was very little recorded about him and, apart from Child L’s mother’s allegations, there is little information in agency records that describes his relationship with Child L and what care he provided. There is even less information recorded about mother’s recent partner who was probably visiting the household from September 2009 and resident from January 2010. Child L’s father raised significant concerns with a range of agencies about mother’s previous partner and her most recent one. These concerns included domestic abuse and poor temper control with regard to her previous partner and alcohol abuse by her most recent one. On no occasion did any agency respond to these concerns.

  13. Summary of Lessons • The importance of multi-agency working at the earliest stage. A number of agencies had separate different information about Child L and the family but no single agency had the full picture. • The importance of effective communication between agencies. • A lack of awareness about the impact that physical and mental health problems can have upon the parenting capacity of a child’s primary carer. • A lack of attention by agencies to the men in this family with little recording of information about them. • The complexity of working with families where there is significant marital discord and where domestic abuse is a possibility.

  14. Children J & KA Brief Summary will be provided as the case is ongoing S.C.R Gender: Male Age: 3 Years old Gender: Female Age: 2 years old Summary: Mother walked into Police station stating she had killed her children. The Police found 2 black holdall bags in the boot of the car. Both bags were opened and a child was found in each one. Both children confirmed dead.

  15. Background Information • Children J& K lived with their biological parents and two half-siblings, in East Sussex until September 2009, when they moved to Lightwater in Surrey. Their mother was allegedly fleeing domestic violence. It is known that mother was registered with a GP in East Sussex since 1992 until September 2009. • J & K had a full-sibling who was the subject of a Sudden Infant Death at the age of 10 months in 2004. Therefore both J and K were monitored under the CONI (Care of Next Infant) Scheme in East Sussex until K s 2nd birthday. • J& K had attended their GP in East Sussex regularly for routine checks and immunisations. When the family moved to Surrey they were briefly registered with a local GP and had routine contact by the Surrey Community Health team. • Surrey Police became involved with the family in September 2009 when the estranged husband made a call to the Police expressing his concerns for the safety of his wife and two children, which the Police investigated. There were several alleged incidents of domestic violence subsequently, which were investigated by Sussex and Surrey Police, the last one on the 26/1/10. • It is known that mother worked in a stressful finance job in the City of London until she was made redundant in June 2009. Mother reported receiving the news on the anniversary of her daughter’s death in 2004. • Mothers relationship with Partner 1, commenced some time before 1991 as health records show that she suffered a miscarriage in 1991, prior to the birth of their first child, in 1993. Records also show that they were married and separated some time before 2003.

  16. Child Q S.C.R Gender: Male Age: 1 Year old Summary: Q was found face down in his bath water, a sibling was also in the bath at the same time and the mother was present at the home address. The incident took place in the family home, Q died on the 16th of September 2011.

  17. Background Information • Child Q and his family were reported to be white British, English was their first language. The family describe themselves as Christian and Child Q was christened at the hospital shortly before he died. The family was working class with a clear work ethic • Child Q’s mother had a very troubled childhood and adolescence. She had intermittent CAMHS involvement from the age of 8 and had a history of behavioural problems in school. BC was known to Surrey Social Services as a child Despite some assessment and child protection investigations there was no effective response to protect BC or GC from further harm as their mother resisted social work involvement. • mother was known to have a history of middle ear and hearing problems In adolescence and a history of drug and alcohol misuse. She attempted suicide when 16 and suffered from depression. Maternal grandfather was reported to suffer from schizophrenia however, this has not been substantiated. • Mothers name was removed from the GP list in 2008 for verbal abuse and aggression and during her adolescence issues of noise nuisance and anti-social behaviour including alcohol and drug misuse. BC also stood trial for murder in 2006 however the case was dismissed against her and it is unclear as to the degree of her responsibility in this matter. • Child Q’s Father also had a significant past history of drug and alcohol misuse he was prosecuted for a drugs offence in 2008. Child Q’s mother and father and maternal uncle and paternal aunt have criminal records for drug offences • Apart from the information about his criminal history very little is known about Child Qs father although it is noteworthy that he is significantly older than BC in August 2002 Child Qs was involved in a domestic incident

  18. Key Issues Identified • Lack of Integrated working by agencies • A key aspect of work with this family was that despite there being significant input by a range of agencies over a significant period of time there was no joint working and no comprehensive assessment of need although there were a number of opportunities for this to have happened. In particular there should have been joint working between GP, midwife and health visitor prior to the birth of both children which would have enabled all professionals to have a better understanding of BC’s own history and therefore the likelihood that she could struggle as a parent. There was considerable discussion within the SCR Panel as to the reasons for the absence of joint working and it was clear that this was mainly because the midwives were not aware of significant information about BC’s childhood which would have triggered a pre-birth assessment. • There could also have been better joint working and assessment on the two occasions that BC was known by the police to have been drunk and incapable of looking after the children. On both occasions the police checked on the immediate safety of the children and passed information to LA1CC There was however, no follow-up on that information, There were a number of occasions when police reports received by the LA1CC were not fully understood • Another opportunity for intervention was when there were allegations about substance misuse known by both the housing association and the police. This was not investigated as a crime by the police and although some information was passed to LA1CC there was no consideration by the police or housing association of formally referring the family to children’s services for an assessment of the impact of the substance misuse on parenting capacity. • During the period of the review there was intervention with the family from midwifery; health visiting; GP; police and housing association but despite some communication between these professionals there was never a point at which all of the information available was shared. • Communication between the professionals working with this family was not positive. There was no direct contact between the midwife and the health visitor or the GP and the health visitor. It was evident that the professionals working with the family did so in isolation.

  19. Key Issues Identified • Lack of professional curiosity by professionals • Associated with the lack of integrated working by professionals involved with this family was a lack of assertive professional curiosity by most agencieswho rarely explored more fully the reasons for events and seemed to accept at face value information that was given. There was an absence of critical analysis of explanations provided even when there was clear evidence of discrepancy. • Effective intervention with families requires an open and questioning approach that considers a range of explanations for events and which is challenging and assertive in response to denial or fabrication. This is particularly true when working with individuals who may be less than honest and feel threatened by professionals and are therefore not co-operative. BC had a long history of failure to co-operate with authority and was unlikely therefore to be frank and open with professionals. • The importance of listening to friends, family and neighbours • Another aspect highlighted within this review was the importance of listening to and investigating all concerns that friends, family and neighbours raise, even if they do appear malicious. Clearly there is the potential for such allegations to be untrue and that should be accommodated in the evaluation; but it is also probable that friends and neighbours see aspects of children’s lives that will never be available to professionals. • Agency interaction with father • This review has identified a pattern previously recorded in serious case reviews of agencies failing to take account of the role of male carers within the family process. ‘There were instances of ‘unknown’ males in some households …….. There appeared to be a minimalist “need to know” attitude to sharing information about the appearance of new men in a household....these men became invisible to practitioners working with the family or child.’ • This reflects a wider issue about the lack of involvement by health and welfare professionals with men despite their significant involvement in children’s lives. The need therefore is for all agencies to ensure that relevant information about men is collected during assessment processes and to ensure that their assessment processes are adapted accordingly.

  20. Key Issues Identified • Focus on the child • This review highlights the extreme vulnerability of young children who because of their total dependency on their carers are at greatest risk of abuse. In the most recent research on serious case reviews just under half of all serious case reviews concern a baby under one year of age. Furthermore this research also showed that ‘many of these very young children do not come to the attention of children’s social care, so the role of GPs, midwives and health visitors, ... is crucial for this highly vulnerable group’. • Another aspect of the work undertaken by agencies with this family was the lack of focus on the children. Most of the energy was invested in working with BC which made some sense given how young the children were. There was however little consideration of needs beyond their immediate safety. In particular there was no assessment of the mother’s parenting capacity and the longer term impact on the children of mother’s vulnerability and difficult behaviour on their development. • The review process has identified that BC was a woman who had a personal history of abuse and maltreatment which meant that her capacity to build effective relationships and to parent effectively was limited. The sense is that she was a needy person and that the health visitor (who was the only professional with whom she developed any professional relationship) was pulled into responding to her problems; and lost focus on the needs of the children. It is very important when working with resistant families to ensure that the work is child-focussed ‘… professionals working with highly resistant families need to refocus their gaze towards the relationship between the parent and the child, rather than focusing too exclusively on the relationship between the parent and the professional’ this has been described as maintaining a ‘child’s eye view’ during assessment and treatment.

  21. Summary of Lessons • Relevant information from BC’s early history was not accessed by the midwifery service or the health visitors because the mother did not volunteer the information and the GP did not share it with midwifery. • The need for better integrated working prior to child protection concerns being identified to ensure better early intervention. The importance of the Common Assessment Framework and Team Around the Child processes being understood and adopted by all agencies. • The importance of all assessment processes including effective assessments of men, particularly fathers. • The need for agencies who do not work directly with children and who are commissioned by agencies whose prime responsibilities are not to children to be better integrated into the LSCB safeguarding systems. • The need to consider whether the current information sharing arrangements between police and other agencies are sufficiently refined to ensure that all information is shared when necessary. • The dangers of concentrating too closely on the needs of the adults which can lead to the children being overlooked and the importance of professionals being sufficiently curious and assertive enabling them to ask the right questions. Particularly the need for professionals to take seriously information that is provided by family and neighbours as this is often information that is not known to professionals.

  22. Child 4 C.R Gender: Male Age: 8 Years old Summary: On 31.1.11 Child 4 was admitted to hospital having suffered physical trauma.

  23. Background Information • Evidence suggests that Child 4’s family moved frequently during his first two years of life – records show four different addresses in the west of England. • It is reported in previous records that he was solely cared for by his father from the age of 6 months as his mother was allegedly experiencing drug and alcohol challenges. • Historical documented concerns regarding Child 4’s birth Mother, which included possible neglect and abuse issues of Child 4 and lack of contact between him and his Mother. • Child 4 attendance at the Accident and Emergency department 19.10.2005 where he was diagnosed as having a fractured right femur and admitted • Child 4 attended the same hospital on 27.06.2006 superficial burns to both feet, requiring daily dressing at the hospital • Child 4 was underweight when admitted to hospital on 31.01.2011 (21kgs (2nd Centile), height 124cms (above 9th Centile) and information gathered during this review suggest that there were concerning health issues relating to all of the children

  24. Key Issues Identified • Articulate parents who hold professional positions of authority can impact upon how agencies assess safeguarding risks for the family. • 2. Referrals do not routinely make clear what the concerns for the child are and the evidence for these concerns. • Children are not listened to. Child 7 repeatedly raised concerns about Child 4’s welfare as well as her own to school but these were dismissed and she was labelled as a liar. Child 4 made statements about Child 7 but these were disregarded. • Background information on children and their families, particularly when they move frequently between counties, is not always kept up to date. • 5. Many professionals involved at various points with family members lacked professional curiosity that would drive them to interrogate information further and identify possible areas of concern. • 6. Contingencies for management of cases. Plans were not routinely in place in some agencies for the management of this case when senior managers were absent. • 7. When children part of newly formed families and coming from broken up families with DA issues, professionals to be mindful of increased vulnerability of child as stepchild (potential source of friction between the couple, scapegoat by siblings/parents).

  25. Summary of Lessons Professionals to record all information and discussions in children’s files to provide comprehensive picture. All professionals to comply with their own agency and SSCB procedures. All SSCB agencies to utilise the Common Assessment Framework when appropriate. Cross-county cooperation: when children move into Surrey from other counties or when children from Surrey move into other counties, a system of exchange of information on the child’s and family’s background should be in place. When there are safeguarding concerns, these should be highlighted to professionals (particularly school and/or GP) of the new county.

  26. Children 1,2 & 3 C.R Gender: 3 x Male Age’s: 3yrs old, 2yrs old & 2months old Summary: On 1 December.2010 the children’s mother died as a result of a stab wound to the neck. The incident took place at the family home.

  27. Background Information • Mother has children from another relationship who live with their father in Yorkshire • Between 5 September 2008 and 1 December 2010, Surrey Police created a total of 8 crime / non-crime reports in respect of the family • concerns regarding domestic violence • There were concerns about stability of the marriage • Mother has a history of mental health issues, self-harming and was on medication for narcolepsy. • Mothers mental well-being seemed to deteriorate during 2010 culminating in her children (1&2) being placed on Child Protection Plans.

  28. Key Issues Identified Loss of focus on the children mother’s mental health issues and self-harming behaviour as well as marital discord and domestic abuse were two factors that impacted on professionals’ ability to maintain focus on the children. Resistant Families: The review has made clear that professionals involved in this case were working in a context of extreme resistance. Impact of Parental Social Status: Both parents were white, middle class, professionals and it is evident from the review that this impacted on the working of the case. On several occasions professionals failed to see the children alone to ascertain their wishes and feelings and instead took parents’ reassurances at face value. Lack of Challenging Supervision: Clearly this case presented many challenges to professionals involved. As the case progressed, some managers also lost sight of what it might be like to be a child in this family. Sharing of Information: There is no evidence that individual professionals working with family members had complete information about them, despite there having been a child protection investigation followed by child protection plans.

  29. Summary of Lessons Staff and managers must ensure that they focus primarily on the children when working with families where adults demonstrate manipulative behaviours, heightened needs and/or mental health problems. Professionals should be mindful that parental social status should not impact upon their professional curiosity and independent judgement when assessing and working with such families. Professionals must ensure that they listen to adults, particularly relatives, who are trying to speak on behalf of the child and who can contribute important information Managers should ensure that they provide regular, robust and challenging supervision and enhanced management oversight when professionals are working with resistant families and assist in devising case-specific strategies for particularly challenging cases. Professionals must ensure that prescribed timescales are adhered to. Decision to make a child subject to Child Protection Plans must always identify the risk to the child and specify what needs to change to enable the child to come off the Plan. SSCB member agencies should consider how to improve information sharing particularly in cases where agencies are dealing with resistant families.

  30. Child R C.R Gender: Male Age: 4 months Summary: Child R was found apparently lifeless in the early hours of Boxing Day 2011. He had been sleeping on a sofa with his mother. Resuscitation was attempted and he was taken to hospital but his death was confirmed that day. The cause of death was subsequently identified as Sudden Infant Death Syndrome..

  31. Background Information • Child H started school in 2008 and there were attendance problems from the outset. • From 2011 Child H’s non-attendance at school became an increasing problem. The school made a referral to Children’s Social Care. This did not highlight safeguarding concerns, although it did refer to Child H as a “young carer” and mentioned some of Ms J’s health problems. • Ms J was became pregnant with Child R and during her contact with ante-natal services made disclosures of previous substance misuse and a history of mental health problems. • After Child R was born the Health Visitor felt the family needed assistance and made a referral to Homestart,. A member of Ms J’s family then contacted Children’s Services, saying that Child H was not being adequately cared for and the home conditions were poor. Shortly afterwards police were called to the home and found that Ms J had taken alcohol and an overdose of anti-depressant medication.

  32. Background Information • Ms J “opened up” to the health visitor, describing an unhappy childhood in a family where there were problems of domestic abuse and misuse of drugs and alcohol. She did not disclose the extent to which she herself was dependent on alcohol. • Ms J then saw mental health professionals. It was felt that her condition could be managed appropriately in primary care • At Christmas, while Mr K was looking after Child H, Ms J and Child R fell asleep together on a sofa. She awoke to find Child R apparently lifeless. An ambulance attended without delay. Child R was taken to hospital and resuscitation attempted but this was unsuccessful. • While Mr K was looking after Child H, Ms J and Child R fell asleep together on a sofa. She awoke to find Child R apparently lifeless. An ambulance attended without delay. Child R was taken to hospital and resuscitation attempted but this was unsuccessful.

  33. Key Issues Identified • There was never any cause for concern arising directly from Child R’s presentation. However Child R’s death may have been prevented, if safe sleeping precautions had been taken. Relevant agencies were not all sufficiently alert to the need to ensure that safe sleep messages were given and re-asserted. • Maternity services were not aware of significant previous medical information held at the same hospital. This is not the first time that this has occurred. Communications within maternity services were flawed so that not all staff were aware of the extent to which Ms J admitted using alcohol. Although potential safeguarding concerns were identified and explored by the Named Midwife, scrutiny was not sustained. There were serious problems in the post-natal discharge arrangements. • The issue of misuse of alcohol was not given adequate weight in assessment and follow-up by various agencies. • Agencies did not work well together to tackle the concerns for Child H, whose school attendance should have led both to enforcement action and to co-ordinated assessment of welfare concerns. There were missed opportunities to explore the family circumstances through the Common Assessment Framework and through the use of Core Assessment arrangements. • There are numerous correspondences between the findings of this review and issues arising from a recent Serious Case Review in Surrey. This may mean that issues arising in this case are already being tackled. That should be examined more closely.

  34. Summary of Lessons 1. The Board should • continue to publicise the importance of “safe sleeping” and the dangers of “co-sleeping” • develop initiatives to promote awareness of the importance of “safe sleeping” among professionals and agencies working with families where there are concerns about the misuse of drugs and / or alcohol 2. The Board should consider the findings of this case review in the light of similar issues arising from a previous Serious Case Review (Child Q, April 2012). 3. The Board should ensure that that any continuing difficulties in service delivery are identified and addressed. 4. The Board should remind all agencies of the requirement to take account of ethnicity and other issues of diversity in their work with families. 5. The Board should, when carrying out case reviews, ensure that all agencies address issues of ethnicity, gender, disability, sexuality and any other personal circumstance that may cause people to be treated unfairly.

  35. Child CB Gender: Male Age: 4 months old Summary: On 26/04/2011 CB presented to the Epsom Hospital A&E with a history of being unresponsive and bruising.

  36. Background Information • Mother has a history of depression, drug and alcohol misuse, post-natal anxiety. • 2010 unplanned pregnancy in new relationship. • Breakdown of relationship both during the pregnancy and approximately 2 months postnatally. • father unable to cope with pregnancy • Financial issues due to fathers unemployment.

  37. Key Issues Identified • Form CP 1 Safeguarding Medical should have the time of completion incorporated within the proforma. • Midwives should consider completion of a Common Assessment Framework (CAF) when additional needs are identified during the antenatal period. A record of the number of CAF’s completed should be monitored on a quarterly basis by the Named Midwife. • There is currently no system for tracking, and retrieval of hand held maternity notes. Maternity services needs to address this. • There was no documentation that previous HNA’s have been reviewed and updated • Correct level of services being provided need to be accurately documented on records • Consideration needs to be given to a robust mechanism of information sharing between GP and midwife.

  38. Conclusion There are a number of key issues that arise from the Case Reviews including: • Communication e.g. information sharing • Adult child interface issues • Resistant families • Staff supervision • Lack of adherence to procedures • Lack of information of male partners