child1 may2009 by 98w4iY


									                          APPENDIX 1




            MAY 2009

This report is published by the Wrexham Local Safeguarding Children Board. This is a
multi-agency group that has responsibility to oversee how services and professionals
within Wrexham cooperate and work together to safeguard children and to make sure
that the inter-agency arrangements in place within the county bring about positive
outcomes for children.

The Local Safeguarding Children Board in Wrexham operates under Government
Regulations that came into force in 2005. These Regulations require all Local
Safeguarding Children Boards to set up a serious case review when abuse or neglect of
a child is known or suspected and a child dies or sustains a potentially life-threatening
injury or serious and permanent impairment of health or development.

This review was set up as a result of injuries sustained by a 16 week old infant. The
main objective of the review was to identify steps that might be taken to prevent similar
harm occurring in future. In doing this, the review set out to:

      establish whether there were lessons to be learned from the case about the
       way in which local professionals and agencies work together to safeguard
      identify clearly what those lessons were, how they would be acted upon, and
       what was expected to change as a result; and as a consequence:

            o identify issues in inter-agency working in order to better safeguard
               children; and
            o identify examples of good practice.

The review was conducted under the guidelines set out in the Welsh Assembly
Government document Safeguarding Children – Working Together under the Children
Act 2004.


This serious case review looked into the case of a 16 week old infant with a head injury
reportedly sustained when he hit his head on the hearth after falling backwards while
trying to sit up unaided. The doctor who examined the child was not satisfied that the
injuries to the child were compatible with the explanation given of how the injuries had
occurred. Following further medical investigations, which revealed that the child had
linear and bilateral skull fractures, the child protection procedures were invoked and,
when the child left hospital three days later, he was discharged into the care of his
maternal grandmother.


Following the injuries to the child, the Local Safeguarding Children Board met and
agreed that a serious case review should be carried out to examine the involvement of
agencies with the child and his family, starting from the first antenatal contact with the
child’s mother and ending when the child was discharged from hospital and
accommodated with his maternal grandmother.

The serious case review panel was made up of representatives from the National Public
Health Service; the North Wales Trust (Eastern Division); Wrexham Safeguarding &
Support Department within Children & Young People Services; North Wales Police; and
North Wales Probation Service (East Division). The panel was initially chaired by the
Chief Safeguarding & Support Officer from Wrexham County Borough Council and, from
February 2009, by the Assistant Director of Children’s Services, Barnardo’s Cymru.
The reason for the change of chair was to bring more independence to the review
process, in line with one of the recommendations from the Baby P enquiry in Haringey.

Each agency that had been involved with the child and his family was required to
produce a chronology of their involvement, together with a report identifying key aspects
of that involvement. The chronologies and reports were then used as a basis for an
overview report that was compiled by an independent author appointed by the Local
Safeguarding Children Board. The full report, which contained 21 recommendations
and an action plan, was sent to the Welsh Assembly Government on 25th May 2009.


One of the striking things about this case was the presence of a wide range of risk
factors that were known to those in contact with the child’s mother and father. These
risk factors have been identified though research as things that seriously compromise
parenting and place children at risk of significant harm. In this particular case, there
were many risk factors that, in combination, were sufficient to suggest that the child
could be at risk of harm.

In both the antenatal and postnatal periods, there was considerable concern at various
times about the mental health of the child’s mother, the behaviour of the child’s father,
the relationship between the child’s mother and father, and the safety of the child.
Although this concern led to a great deal of communication between professionals and
agencies, no child protection activity was initiated until the child was admitted to hospital
with a head injury.

There are several aspects of this case that were worrying. As with many serious
case reviews, there were communication problems between agencies that affected
the responses made to concerns raised. There were also communication problems
within agencies that were, arguably, more worrying than those between agencies.
More serious were the errors of judgement made at key points, particularly by staff
within Social Services.

The communication gaps identified between Health professionals resulted in a lack of
coordination between those providing services to the family in the period before and
after the birth of the child. This lack of coordination contributed to the delay in
recognising the potential for the parenting of the child’s mother and father to be
seriously compromised. This, in turn, created delay in making a referral to Social
Services and confusion about the subsequent involvement of that agency in the case.
Despite these things, there was nothing to suggest that any of the Health professionals
involved in the case had acted in anything other than a professional manner.

Notwithstanding the concerns about the way the case was handled by Health
professionals, the most serious concern identified related to the way in which staff within

Social Services dealt with the case. On this, there were many examples of practice that
was below an acceptable standard.

Another interesting aspect of the case was the willingness of professionals from both
Health and Social Services to accept statements from the child’s mother and father that
their relationship was improving and that they were committed to being good parents.
Whilst a certain amount of optimism is required in working in the field of child protection,
this case illustrates the need for professionals to be realistic about the potential for
change in and between people whose personal histories indicate they will have difficulty
changing without help and support.

As with all serious case reviews, it is reasonable to consider whether the mistakes
that were made in this case, whilst obvious in retrospect, were not so obvious at the
time. It is difficult to argue that this was the case because what was known at the
time should have been sufficient to trigger child protection activity long before it did.

Alongside the concerns in this case, there were also examples of good practice. The
following examples were the most noteworthy:

1. when the injury to the child was suspected to be non-accidental, a child
    protection referral was made by medical staff at the district general hospital and
    there was a speedy and appropriate response to that referral;

2. staff from the midwifery service maintained contact with the child’s mother
    throughout her pregnancy, despite her frequent changes of address;

3. babies are not allowed to be taken off the postnatal wards for safety reasons and
    are transferred to the nursery when mothers leave the ward;

4. the health visitor completed a holistic family health assessment and identified
    that the family needed additional support from the service;

5. when the midwife and the health visitor recognised that the child’s mother was
    showing signs of being depressed, they referred her to the GP.


The review made 21 recommendations, all of which have implications for practice. The
Local Safeguarding Children Board has accepted these recommendations and
incorporated them within an action plan for implementation over the next 12 months.

The recommendations made were as follows:


1. Each new incident that raises concern that a child may be at risk of significant
    harm must be referred to social services duty and assessment team even if the
    case is open to Children’s Social services.

2. Where families have complex needs, an assessment using the “Framework for
    Assessment of Children in Need and their Families” must be completed and
    recorded in the relevant health records (adult and child).

3. Where health professionals identify that a family need an enhanced service, this
    should be recorded in the records as an assessment, a plan and an evaluation of
    the plan.

4. The NHS Trust should audit compliance with recommendation 3).

5. Where more than one health service is working with a family with complex
    needs, a health professional planning meeting or a multi-agency meeting must
    be convened and a key worker identified.

6. The Midwifery Services within the NHS Trust should review the care pathway to
    ensure that, where there are current or historical issues of drug and alcohol
    misuse, mental illness and domestic abuse, there is a holistic assessment
    carried out and a multi-agency plan in place.

7. The NHS Trust provider service should audit compliance to their standard of an
    antenatal visit to parents where the mother is expecting her first child.

Social Services

8. Full compliance with departmental policies and procedures should be monitored via
    the supervision process and case audit.

9. There should be a clear system in place to ensure that referrers are kept informed
    about how Social Services are dealing with the referral received.

10. Guidance should be issued to Safeguarding & Support Department staff clarifying
    who is responsible for recording management discussions and decisions to ensure
    that crucial information is not lost and staff are clear about their roles and

11. Guidance should be issued to Safeguarding & Support Department staff clarifying
    who is responsible for undertaking background checks on RAISE and with other
    agencies, the extent of those checks and the way in which the information should
    be recorded on the RAISE system.

12. Supervision discussions should be recorded on RAISE case files.

13. Introduce mandatory child protection training for all Safeguarding & Support
    Department staff, which should include the requirement for staff to attend annual
    Child Protection Multi Agency training to update their knowledge and skills.

14. The LSCB Training and Development Officer should keep a register of all
    Safeguarding & Support Department staff attending Child Protection Training and
    be responsible for alerting Team Managers and Service Managers of non-
    compliance with Child Protection training requirements.

15. The LSCB Training and Development Officer should produce an Induction Manual,
    to be issued to new staff within one week of joining the Safeguarding & Support

    Department. The Induction Manual should also be made available to all staff via the
    Local Authority intranet.

16. All child protection training should be delivered by individuals as specified in the
    LSCB Annual Training Plan.

17. A review should be undertaken of the management capacity within the Child and
    Family Assessment Team (CAFAT).

18. Social Services and Probation should review their response to the domestic
    violence incident that was reported in September 2006 in order to identify any
    practice shortcomings.


19. Probation should be more actively involved in Multi Agency Training to ensure all
    agencies understand the role and work of the Probation Service and the part the
    Service has to play in protecting children.

20. Probation should ensure that the service has a representative on the LSCB Training
    Sub Group.

    All Agencies

21. All staff should be reminded of their duty to follow the All Wales Child Protection
    Procedures in situations where child abuse is suspected or reported.



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