| Serious Case Review re 'D' |
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Tameside Safeguarding Children Board has published a Serious Case Review Executive Summary, re child D, completed in February 2010. 1.0 INTRODUCTION 1.1 This report is the executive summary of the findings from a Serious Case Review that was held in order to consider agency involvement with Child D. 1.2 Reports of this nature are required and shaped by the statutory guidelines in a Government document entitled “Working Together to Safeguard Children” – (available from The Stationery Office – www.tsoshop.co.uk.) 1.3 Working Together sets out expectations of organisations and individuals who have particular responsibilities for safeguarding and promoting the welfare of children. 1.4 Chapter 8 of these guidelines is headed “Serious Case Reviews” and sets out the circumstances when a child’s death or serious neglect should prompt a review of the involvement of organisations and professionals with the child and family; that review is expected to consider whether there are any lessons to be learnt that might shape future responses and practice in similar cases. 1.5 Serious Case Reviews are not inquiries into culpability; that is a matter for Criminal Courts to determine, as appropriate. 2.0 BACKGROUND 2.1 Child ‘D’ was nearly 2½ years old when he was admitted to hospital and found to be “extremely underweight, malnourished and with significant developmental delay. He was unable to stand, walk or talk and was severely emaciated, with wasted buttocks ……”. He was later diagnosed with possible liver damage due to starvation. No organic causes were found that could explain his condition. 2.2 His ‘emaciated state’ was ‘spotted’ by a member of the public who reported her concerns to local school staff, who were able to identify the family and forward a report to the local Children’s Social Care services. 2.3 At the time of the referral, Child ‘D’ was living with his older half sibling ‘L’ with their single mother ‘M’. ‘L’ was described as generally healthy, but somewhat withdrawn; subsequent checks determined a significant history of poor school attendance for sibling ‘L’. 2.4 Child ‘D’ remained in hospital for some time whilst half sibling ‘L’ was placed with relatives. Child Protection investigations, police investigations and core assessments all followed to determine a full history and future plans for the children. The very serious condition of Child ‘D’, apparently not noticed by statutory agencies, prompted the decision to complete a serious case review. 3.0 THE PROCESS AND HISTORY 3.1 Child ‘D’ and his half sibling are children of white/UK ethnicity. They were not subject to any formal orders, previous child protection plans or any previous registration of concerns. Neither child had any known or recorded disability. Issues of race, religion and language have been considered but not identified as factors in this case. 3.2 The first recorded contacts with the family were in 1995 when mother registered as a new patient with her current medical practice. The subsequent Individual Management Review by Health has identified some earlier history of mental health issues for mother; mostly managed by medication. Mother described her own background as “unremarkable” and identified no significant difficulties or health issues. 3.3 Her first child was born in 1996; ante natal and post natal reports were largely ‘uneventful’ and most subsequent health reports on ‘L’s care and development were sound. 3.4 Mother was recorded as a ‘single parent’; in early 2002, police responded to two incidents of ‘domestic violence’, involving her estranged partner (J), father of ‘L’. These reports were shared with health and social care agencies; they were recorded but prompted no further follow up or assessment. Mother described her separation as amicable, denied any suggestion of domestic violence and still sees her ex partner as supportive. 3.5 By July 2006 school was beginning to note a significant deterioration in ‘L’s school attendance which continued over several years and eventually resulted in prosecution and a court appearance for mother. 3.6 Over the same period ‘L’ had been presented to hospital on numerous occasions, initially with minor head and facial injuries; subsequently with what mother reported as ‘fits’. None of these were considered significant or suspicious, no trends or patterns were considered and no underlying condition was found in ‘L’. 3.7 Mother had been attending her G.P. on regular occasions, with frequent references to her continued history of anxiety and panic attacks, including one reference to an eating disorder. She chose not to refer to any of this when making her contribution to this review. 3.8 Child ‘D’ was born early 2007; again, the reports of ante natal and post natal care were either unremarkable or good. Mother says she was delighted to have a second child, despite her separation from his father. His subsequent care and initial development caused no concerns to the health agencies that saw him. 3.9 Specifically, in March 2009 he was seen at a health clinic and in April 2009 he was seen at G.P surgery.; he was not yet walking and was referred for follow up to check gross motor development, otherwise both reports described him as healthy and happy, with no mention of weight and no suggestion of neglect. Mother maintains he was ‘thin’ at this stage, although she had no particular concerns, as most family members are ‘thin’. She now recognises how very poorly he was when finally admitted to hospital and wishes that any concerns had been raised with her at this much earlier stage. 3.10 The significant, undetected, decline in ‘D’s weight, with the potentially serious consequences outlined, eventually led to statutory interventions to protect him and his sibling. As circumstances emerged, they also prompted the decision to review agency involvement, agency decision making and any lessons to emerge. 4.0 KEY ISSUES 4.1 Terms of Reference were agreed and included requirement(s) for each agency to:-
4.2 The primary lead for this Serious Case Review was the Tameside Safeguarding Children Board. The Serious Case Review Panel (of the Board) took the initial lead for assessing and evaluating the criteria for a review, and for deciding the scope and terms of reference. 4.3 The Serious Case Review Panel (S.C.R.P.), under independent chairmanship, also took responsibility for progressing the review, for producing the Independent Management Reports (I.M.R.s) and the final Overview Report. The primary membership, and/or contributors to that group, and to the subsequent I.M.R.s, was as follows:- - Independent Chair - TSCB Development Manager - Detective Sergeant, Greater Manchester Police - Service Unit Manager, Tameside Services for Children & Young People - Principal Education Welfare Officer. - Executive Director of Nursing, NHS Tameside - Assistant Executive Director, Specialist Services and Safeguarding - Principal Education Psychologist - Associate Director, NHS Tameside & Glossop Provider Division 4.4 The Serious Case Review Panel held on 20 October 2009 focused on the medical history and the medical condition of ‘D’, and considered the need for further ‘expert opinion’. The author of the Health I.M.R. was asked to liaise with the Paediatric representative of the Safeguarding Board to examine in detail how ‘D’s condition might have deteriorated and/or gone undetected between the final health contacts (at clinic and G.P. surgery) and his hospital admission. 4.5 It was also agreed at the same Panel that parents of ‘D’ should be informed of the review and invited to meet the Independent Chair and/or Independent Author to share their experiences and expectations of support services. By mid December, mother had been approached and agreed to meet with the independent author of the overview report. Her views and contributions are reflected in the body of the final report and the Executive Summary. Consideration was also given to if/how ‘D’s father should be notified and engaged in the exercise; he was approached but did not respond. 4.6 Involvement with this family and both children had been significant; between his birth and hospital admission, Child ‘D’ had been seen by various health services on 29 occasions. Older half sibling ‘L’ was at school and there was extensive involvement from the education welfare services. 4.7 According to medical records, mother had a history of ‘mental health issues’, mostly described as anxiety and panic attacks. These were treated with medication. This is not a history she chose to recognise or share when invited to contribute to the review. 4.8 Early interventions were provided on a ‘universal’ basis, but no agency considered the more formal use of multi agency work, C.A.F., or the possible benefits of prevention services such as Children Centre(s). 4.9 Services specific to ‘D’ were largely through primary health who saw him on a regular basis and were satisfied with his care and progress. Despite engaging ‘expert opinion’, no formal explanation has been offered for the ‘drastic deterioration’ in ‘D’s condition from when he was seen by H.V. and at G.P’s surgery in March and April 2009, to his hospital admission. Questions have been raised about the nature of assessments on both those occasions, and the recommendations of this review reflect that. 4.10 There is some confusion also about the timing of the ‘referral’ in relation to ‘D’ by the member of the public. It was followed by some delays by Children’s Social Care and even though an ‘initial assessment’ was in progress, it was a full week before this ‘seriously neglected’ child was admitted to a place of safety. That too is reflected in recommendations. 4.11 The Review process and the I.M.R.s have recognised that a great deal of information was held on this family, certainly following the birth of ‘L’ and the subsequent birth of the subject, ‘D’. - There was information about mother’s mental health - Information about her status as a single parent and at least two incidents of domestic violence - Information about frequent minor injuries or health concerns, re ‘L’, presented by mother - Information about ‘L’s very poor school attendance - A final point of information presented by a member of the public who was the ‘first’ to recognise how serious ‘D’s condition had become. Until this last point, there had been no single or major event and no level of recognised concern to prompt any agency to trigger some form of multi-agency meeting and assessment. 4.12 Many agencies were offering very significant levels of support to mother and her children. It does, though, highlight again, the importance of information sharing and the benefits of multi-agency working if early identification and early intervention are to be successful, especially for ‘hard to reach’ families. 4.13 These points have been recognised by the Serious Case Review Panel and are reflected in the range and volume of recommendations. 5.0 RECOMMENDATIONS 5.1 The whole of this exercise, and therefore these recommendations, has been constructed in the knowledge that care proceedings, police investigations and possible prosecution are still pending. Those further proceedings are not necessarily critical to reviews of this nature, or to any early lessons that can be quickly identified and applied. It does, however, leave a small but important qualification that something could yet emerge that provides a fuller, or clearer, account of background information and circumstances which, by association, could better inform this understanding of the family’s needs and what might have been needed to better support them. 5.2 The primary agency involved with ‘D’ has been the health service in Tameside; specifically the family G.P. and the local H.V. The family was also known to the local primary school and E.W.O. service in relation to ‘D’s older half sibling, ‘L’. Tameside Children’s Social Care and Greater Manchester Police both became involved at later stages to investigate and address the serious concerns emerging re ‘D’s welfare and safety. 5.3 A number of very significant and helpful recommendations are cited in most of their reports; they are detailed here, together with other recommendations that this overview exercise has identified, or emphasised. Health recommends that: i. A process is developed by GPs for GPs to share concerns relating to relevant concerns about parents with children under 5. The same process to be utilised for liaising with school nurses for parents with school age children. ii. School nurses to continue to take part in Illness Panels. Process to be formalised between EWO and school nurses. iii. All interventions in connection with family issues should be recorded in the family record and this should be stored in the youngest child’s records to ensure professionals accessing the records are aware of the full picture. iv. Administrative processes are reviewed in the administration of referrals to the community paediatric service and the Gait clinic. v. Weighing guidelines to be written and non attendance is acted on appropriately. vi. Formalise current practice – registration and referral to children’s centres and school nurse attendance on Illness Panels. vii. Raise the importance of information sharing with GP’s and professionals in primary care. Children’s Social Care recommends that: i. Specialist Services and Safeguarding should ensure that all staff in Area Teams act promptly to record new information indicating concern for a child and that this is pursued by the service. The original source of the information should be contacted without delay. ii. Specialist Services and Safeguarding should ensure that referrals and communications which include concern about the physical condition of a child result in the child being seen within 24 hours. iii. Specialist Services and Safeguarding should ensure that referrals of serious physical abuse or neglect are progressed to S47 within 24 hours. iv. Specialist Services and Safeguarding should ensure that First Response visits to children are reported to a manager the same day. Education Welfare Service recommends that: i. Case file audit process to be reviewed. ii. Senior EWOs to complete Supervision Training. The management team will agree a format for cases to be reviewed and decisions made and recorded. iii. The assessment process will be reviewed with reference being given to establishing the support available from the wider/extended family. iv. The EWO involved in the case will attend the multi agency child protection training provided by the LSCB. Advice/guidance will be given to the EWO regarding recording and monitoring will be put in place. Schools service recommends that: i. Conduct review of school policy and protocols in relation to monitoring, recording and responding to pupil absence. ii. Develop guidelines to improve multi-agency working in relation to vulnerable pupils. And i. Conduct review of school based record keeping system for multi agency referrals. ii. Determine the importance of school attendance as a priority record on Joint Assessment Systems. iii. School to review its assessments of pupil concerns that relate to attendance and additional needs. Police recommends that: i. That GMP introduces a standardised system for domestic abuse (DA) notifications which is electronic, auditable, timely and accurate. Overview Writer recommends that: i. The Health proposal to invite GPs to introduce a protocol on information sharing should be informed by HV services and should consider the likely significance of the early health and social history of new mums. ii. Tameside Safeguarding Board should consider the role of GPs in Serious Case Reviews and should inform the eventual protocol that determines if and how G.P.s should be expected to share significant information about parents, with H.V.s and other community health support services. iii. Health Services in Tameside should emphasise the importance of monitoring and evaluating incidents or injuries to young children, not simply recording them. A brief, periodic review should appear on the child’s records. iv. As Health Services in Tameside review the current guidelines on weighing children they should also consider the possible links between mobility problems and neglect, highlighted by this case, and advise accordingly. v. Education Welfare and Schools Services in Tameside should jointly review current guidelines and procedures for addressing non school attendance and for pursuing court proceedings. In particular, that review should consider:- - when levels of non attendance should trigger consideration of a ‘child in need’, use of the C.A.F. and referral to wider joint assessment processes - minimum consultations and assessments required before any case progresses to court proceedings - the importance of detailed and accurate records to be maintained by schools and by the E.W.O. Service and the importance of forwarding reports of child neglect directly to CSC and without delay. vi. All children services agencies in Tameside should be reminded of the importance and value of early interventions and the support services available. The key indicators emerging from this case should have been sufficient to recognise this as a ‘family in need’ and Tameside agencies should be challenged to consider if current communications and/or thresholds are clear and robust enough vii. Police and Children’s Social Care should review present arrangements for sharing information about domestic violence incidents. Delays should be avoided and events should be recorded quickly in order to ensure that case records and assessments are up to date and comprehensive. viii. Health visiting services in Tameside should review their expectations and guidelines when incidents of D.V. are shared with them. ix. Health visiting services in Tameside should review their expectations of ‘new birth assessments’ and consider if this would provide a good opportunity to collect wider health and social information from the G.P. and/or other sources. x.Health Services in Tameside should review the specific and general arrangements for sharing information when ‘child protection checks’ are requested by Children’s Social Care. NB: During the interview(s) with mother and family members they were encouraged to reflect on their own experience and expectations of support from local agencies. They were keen not to make “excuses for their own shortcomings” and were clear that they had not made any specific requests for help. On reflection though, and in the context of the learning that all parties want to take from this exercise, they would now highlight 2 key changes they would like to see:- - fuller assessments and wider engagement by E.W.O. services before court sanctions are pursued (having now been told a little about children centres and family support services mother and uncle believe this might have made a difference) - more attention and advice re issues of weight when young children are seen at surgery or clinic.
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