Tameside Safeguarding Children Board Reports

Serious Case Reviews - March 2009

Child J - Executive Summary

1. Introduction
   1.1 Summary
   1.2 Circumstances of Child J’s death
   1.3 Membership of the case review panel
   1.4 The terms of reference for the review
   1.5 Analysis of action and decision making
   1.6 Summary of agency findings
   1.7 Good practice
   1.8 Recommendations

1 Introduction

1. Child J was a white British male child born on the 21st May 2006 who died on the 23rd November 2006. The cause of death was bronchial pneumonia. He was not subject of a plan of protection.

2. A Serious Case Review (SCR) examined the involvement of agencies with Child J and his family prior to his death. The purpose of the review is to find out if there are any lessons to be learnt to improve how different services and professionals work together. In particular the review looks at whether decisions and action taken by professionals involved with the family were appropriate and whether with the benefit of hindsight anything could have been done differently. The review does not inquire into how a child died and it does not attribute responsibility for a child’s death. That is the responsibility of the coroner and the courts. The parents were convicted of child cruelty and are serving prison sentences.

3. The review began promptly when it became apparent that Child J had been subject of abuse prior to his death. This evidence came to light through the post mortem examination. The completion of the review was delayed to allow the subsequent criminal investigation and prosecution to be completed. Following the completion of the criminal process the coroner decided not to conduct any further enquiries. These processes were completed in early 2009 when the review could be finalised. Work had already begun on taking action in response to the findings of the review panel.

4. The review was ordered by the Tameside Safeguarding Children Board (TSCB). The TSCB provided terms of reference for the conduct of the review and for the individual agency management reviews. The reason for undertaking the review was because of;

• Evidence of significant harm to Child J prior to his death that was not subject of interagency safeguarding action. The case appeared to have implications for agencies and/or professionals working to safeguard children;
• Concerns about the quality of communication and inadequate sharing of information between professionals in contact with the family between May and November 2006;

5. The board arranged for an experienced author to write a detailed overview report. The author is independent of all the agencies and services in Tameside. That report is confidential and cannot be shared with anybody outside the TSCB and specific government advisors who have the responsibility for evaluating the quality of the review and providing advice to the board and to government. An overview report is subject of a Freedom of Information decision that was made in August 2006(1) that made clear that overview reports provided in serious case reviews should remain confidential. This executive summary provides information about the issues examined by the review and its findings.

1.1 Summary

6. The review found failings in how professionals involved with the family shared information, failed to identify indicators of neglect and were obstructed in their contact with Child J. Although individual professionals had some concerns about Child J they were never shared in a formal multi agency meeting or referred to social workers. It is probable that if the information had been shared then different decisions would have been taken to be more assertive about the contact with and monitoring of Child J. This would have included a full assessment of the home circumstances and the extent to which the parent’s were meeting Child J’s needs and keeping him safe. In particular, the fact that Child J was admitted for failure to thrive just over a month before his death should have been recognised as evidence of neglect and the local safeguarding children procedures been invoked. These procedures were not invoked and no referral was made to social workers. Physical injuries in the form of bruising had been identified on a previous occasion although the parent’s explanation was accepted as plausible. Child J was not examined by a paediatrician on that occasion. None of the fractures found at post mortem had been previously identified before his death. It is likely that the parents were aware of these injuries but had taken no action to seek treatment.

1.2 Circumstances of Child J’s death

7. The police initially investigated the circumstances as a special procedures death following the sudden unexpected death of a child. The preliminary examination by the police did not highlight any suspicions or concerns. The doctors initially had no concerns about the cause of death and there were no apparent injuries to Child J’s body. The doctors expressed concerns that the parents had not sought medical treatment more quickly. Child J had been admitted to hospital on a previous occasion when he was failing to gain weight.

8. The facilities in Greater Manchester for paediatric post mortems are at Pendlebury Hospital and therefore there was a delay for Child J’s body to be transferred to Pendlebury. This meant that a post mortem did not take place until a week after Child J died. A recommendation is made at the end of this summary in relation to this delay.

9. During the skeletal x-ray prior to the post mortem, the radiographer noted several fractures of different ages. The post mortem identified that the fractures were non-accidental. The post mortem concluded that Child J had been assaulted on a number of separate occasions. The skeletal x-ray identified fractures of varying ages and dated injuries at 12 weeks, 6-8 weeks, 1-2 weeks and 3-7 days prior to Child J’s death.

10. The serious case review panel was convened in December 2006 in compliance with national guidance. The panel brought together senior experienced staff from relevant services. These included the primary care trust (PCT), the acute trust, police, education and children’s social care services.

11. The PCT and Acute Trust provided detailed management reviews that examined the involvement of health care professionals through the health visiting service, GP and hospital. The police also provided a shorter agency review.

12. The parents had been previously known to children’s social care services. This involvement was prior to the birth of Child J. No referral in relation to Child J was made to social workers until after he died and concerns had been highlighted through the post mortem.

1.3 Membership of the case review panel

13. The panel was initially chaired by the Head of children’s social care services. This agency was not involved with the children and did not provide an agency management review. Since the panel began work, more explicit government guidance has been issued requiring the panel to be chaired by an independent person. An independent chair was appointed to chair the final meeting of the panel. The independent chair was provided with complete reports and minutes of previous panel discussions. The independent chair has considerable senior experience of children’s services and safeguarding arrangements.

14. The case review panel overseeing this review comprised the following:

• Head of Children’s Social Care (CSC) Tameside MBC
• Named Doctor Tameside and Glossop PCT
• Designated Doctor Tameside and Glossop PCT/Named Doctor Tameside and Glossop Acute Trust
• Designated Nurse Child Protection Tameside and Glossop PCT
• Detective Chief Inspector Headquarters Public Protection Unit Greater Manchester Police
• Detective Inspector Public Protection Unit Greater Manchester Police
• Head of Access and Equality (Named Person for Safeguarding) Tameside MBC
• Service Unit Manager (Quality Assurance) CSC Tameside MBC
• Named Nurse Child Protection Tameside and Glossop Acute Trust
• Independent author of the overview report

The coroner had an observer at three meetings of the panel.

1.4 The terms of reference for the review

15. The TSCB provided terms of reference for the conduct of the review and for the individual agency management reviews.

The purpose of the Review is to;

1. Establish the facts of the case in relation to each individual agency.

2. Consider the events, the decisions made and actions taken or not taken.

3. Establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.

4. Identify clearly what those lessons are for each agency, how they will be acted upon and what is expected to change as a result.

5. As a consequence, improve inter-agency working and better safeguard and promote the welfare of children.

6. Establish a clear action plan for individual agency implementation.

7. Provide a multi agency overview report in accordance with Working Together to safeguard Children Guidance.

8. Particular issues identified for further investigation by the health agency management reviews:

• To consider information about the involvement of the Health Agencies from 01st September 2001 for mother, 02nd July 1996 for father;
• To review issues relating specifically to recognition, co-ordination and communication among health professionals;
• To assess whether the actions taken by health professionals were in line with relevant policy, procedures and good practice guidelines.

9. To develop a clear multi agency action plan from the overview report.

10. Provide an executive summary for publication.

1.5 Analysis of action and decision making

16. Analysis of the events prior to Child J’s death revealed that health professionals had considerable difficulty in securing good working relationships and arrangements with either parent. It is apparent that both avoided contact between professionals and the child on several occasions. They did not seek treatment for Child J on any of the occasions he was physically injured. They did not seek advice and help when it was becoming apparent that he was not putting on weight and had developed a cold injury in October 2006. Treatment was provided as a result of the health visitor recognising that there was a problem and contacted the GP who made an urgent referral to the hospital. This action by the health visitor was good practice. This could have provided an opportunity for all the relevant agencies to have been consulted and to have shared information that would have included previous history. However this did not happen.

17. Child J’s treatment at the hospital in October 2006 was primarily treated as clinical symptoms. Although tests confirmed there were no medical reasons for Child J not to put on weight, senior medical staff were led to believe that Child J’s parent had recognised he had not been feeding properly. The hospital allowed Child J to be discharged from hospital without a plan other than for Child J to be examined at a follow up clinic. This decision was taken because of inadequate information being available about previous concerns of other health colleagues.

18. The review highlights that information was not coordinated and those indicators of potential harm were not recognised, or were not acted upon with sufficient rigour except for one notable exception. A significant factor was the degree of optimism that influenced key judgements and decision making especially in the absence of an accurate social and family history or the effective co-ordinating of information between different health professionals.

19. The agency reviews identify a serious failure of roles and non-recognition of risk and significant harm to a very young dependant child. Child J’s failure to thrive which led to his admission to hospital in October 2006 was primarily treated as clinical presentation of symptoms rather than signifying preventable neglect. There were indicators that Child J was being neglected prior to his death. The parents obstructed health professionals’ right up to the point Child J was admitted for failure to thrive in October 2006. The consultant mistakenly believed that a more trusting relationship was established with mother leading to the decision to allow Child J to be discharged within 24 hours of admission for tests and observation. The panel believe that the parents tried to control professional involvement through a range of behaviours that included avoidance of contact and aggressive behaviour.

20. The social and family history of the parents was not fully known and therefore not fully understood by the health professionals working with the family. This was in spite of some early indication of potential difficulties relating to use of alcohol, anger management and coping with the demands of being new parents. Misleading information was provided about lifestyle and health professionals had no accurate information about the home circumstances.

21. Following the discharge from hospital after Child J’s birth the parents avoided planned contact with health care professionals and to bring him for ultrasound scans.

22. The community midwife saw Child J in June when he was gaining weight and he was discharged from the care of the midwife. No formal handover was made between the midwife and the health visitor.

23. Between the end of June and mid October 2006 the child was not seen by a health visitor in spite of her attempts to see him on four separate occasions. The PCT had no policy for no access visits or contacts although has subsequently introduced this. The avoidance of services or contact with health professionals should have triggered an early discussion with the PCT safeguarding unit or making a referral to children’s social care services.

24. Child J was seen at the GP surgery in August and October for his routine immunisations. During the visit in August a health visitor felt a lump on Child J’s lower leg but there was no bruise or break to the skin. No concerns were noted by the GP during a full physical examination of Child J.

25. The original concerns of two midwives were never brought to the attention of the community or Sure Start health visitor who only managed to get access once until the visit in October 2006 when Child J’s condition has deteriorated to such an extent that an urgent referral was made for failure to thrive. He had also been physically injured on more than one occasion for which his parents have not sought treatment. This was not detected until after his death and a post mortem examination was completed.

26. Opportunities to intervene were not recognised and the significance of indicators of risk was underestimated. The GP referral of Child J for failure to thrive led to a hospital examination that clearly recorded evidence of physical neglect. The paediatrician was not told that Child J had not been brought for his ultrasound scans. Information was not shared effectively.

27. In view of the failure to thrive and the reluctance of the parents to seek medical intervention or co-operate with the suggestion for medical investigations, contact should have been made with children’s social care to share information and make a referral. The failure to thrive, irrespective of the cause, indicated that Child J was potentially a child in need of services and/or protection.

28. The problems with the parental management of Child J’s care were apparent very early on. The midwives at TGH had observed mother having problems in caring for Child J. One of them established that mother had some personal difficulties. Both parents were aggressive in their dealings with hospital staff. Two midwives made a referral to the liaison health visitor. One of the referrals highlighted concerns about parenting skills but did not explicitly request assessment or support in regard to this from the health visitor. This information was not available to the health visitor who undertook the home visit in June 2006. The health visitor concluded, on the basis of the incomplete information and history that mother was coping and was apparently well supported.

29. The agency review by the PCT acknowledges that the process of communication between hospital based staff and community practitioners was unclear.

30. In October Child J was admitted to TGH to investigate urgently the cause of his failure to thrive. The GP stated in his referral that the health visitor was having difficulties seeing the family. Child J’s weight was below 0.4 centile, and was described as thin and emaciated with cold feet. A small bruise was observed on his left knee. He had red toes and crumpled toenails. His parent was reluctant to allow Child J’s admission. In spite of these several worrying indicators and the fact that Child J‘s physical condition improved within 24 hours and no organic reasons for failure to thrive were identified the paediatrician was persuaded by mother to allow his discharge home. The decision was taken ‘reluctantly’. The consultant gave explicit feeding instructions to Child J and arranged an early review in three days time.

31. The agency review by the Acute Trust acknowledges there was an emphasis on Child J’s feeding and that the general condition of Child J and parenting abilities of both parents should have alerted professionals to a higher level of concern.

32. The paediatrician encouraged by Child J’s weight gain and improved physical appearance when he was examined at the outpatient clinic review concluded that a therapeutic relationship was developing with mother who had been previously resistant to other health professionals. The weight gain and improvement of Child J’s overall condition and the apparently improved attitude of mother led the consultant to take a ‘conservative approach’. A consultant review was planned a month later but no arrangements were made for ongoing monitoring. The difficulties faced by the health visitor to see Child J in the preceding months were apparently not taken into account in making this judgement.

33. The Laming Inquiry(2) makes several recommendations for health care organisations relevant to this review. For example when a child has been examined by a doctor and concerns about deliberate harm have been raised, as they were in this case by the GP referral, no subsequent evaluation of those concerns should be considered complete until each have been fully addressed. The inquiry also required chief executives in hospital trusts to ensure no child is discharged without a documented plan for the future care of the child.

34. The local safeguarding procedures already required a meeting to be convened when concerns were identified about a child. The local protocol for convening child and family meetings prior to hospital discharge was agreed by the Area Child Protection Committee(3) in January 2004 and it was integrated into the Acute Trust safeguarding procedures.

35. A meeting was not convened in this case because health professionals in response to Child J’s symptoms had an insufficient level of concern. Initial clinical tests to establish the reasons for failure to thrive were complete when Child J was discharged from hospital. These were inconclusive although a raised platelet count was noted and Child J’s weight and physical condition improved in the short time he was in the care of the hospital. The raised platelet count is a non-specific finding in relation to neglect.

36. Failure to thrive in the absence of any organic or medical factors should alert professionals to a child suffering preventable significant harm. Research evidence indicates that it is a minority of children who have an organic or medical condition that is a cause for their failure to thrive. The purpose of admitting Child J to hospital was to establish what was causing the physical symptoms observed upon admission.

37. Two senior paediatricians physically examined Child J on admission to hospital. The acute trust review found that the examinations were conducted fully and appropriately. No physical injuries were revealed other than a small bruise on Child J’s leg for which mother had a credible explanation. An infant of Child J’s age who had sustained a fracture will usually display evidence of discomfort or distress. Child J did not display such symptoms when examined on the 20th October. No x-rays were taken. Procedures for requesting x-rays are governed by stringent regulations that reflect the risk associated with exposure to radiation. X-rays should only be undertaken if there are clinical symptoms indicated. The absence of an x-ray examination of Child J is consistent with the absence of clinical indicators and the criteria described by the Royal College of Paediatrics and Child Health Companion (section 6.4.11).

38. Some health professionals including the health visitor continued to have problems seeing Child J even after the referral for failure to thrive who sought advice from the PCT named nurse on two occasions although neither elevated their concerns to convening a child in need (CIN) meeting. Following Child J’s discharge from hospital on the 20th October no contact was planned until the Children’s Outpatient Department (COPD) review a month later. The PCT acknowledge that the pattern of failed access visits should have alerted the health visitor to the possibility that Child J was in need of services or protection.

39. Arrangements were made for the health visitor to visit in two weeks. When this appointment was missed the health visitor contacted the paediatrician who advised leaving the matter until the review.

40. The review by the Acute Trust acknowledges that it would have been more appropriate for the consultant to have brought the date of the planned review forward. There was no direct discussion between the consultant in charge of Child J’s case and the community health staff working with the family.

41. The agency reviews from the two health trusts made twelve recommendations to address the issues highlighted.

1.6 Summary of agency findings

42. The health services reviews identify themes that have implications for policy development and staff training that applies to all services working with children. These include:

• Information sharing and communication is vitally important in recognising that individual events that may have little significance but can be interpreted differently when viewed as part of a pattern of behaviour or events;
• The importance of accurate, prompt and complete record keeping;
• Recognising that persistent failure to attend appointments or avoiding contact with key professionals can be an indicator of concern and recognising the potential significance of this behaviour for protecting children;
• Knowledge and understanding about what constitutes neglect;
• Recognising that disguised compliance is a strategy deployed by families reluctant to engage with influential professionals;

Issues highlighted for health professionals in particular include:

• Health professionals had very little accurate information about the family’s home circumstances;
• The two referrals by two midwives should have alerted community staff to the family’s need for support; however the information was not specific in requesting an assessment or providing additional support and was not followed through;
• Health professionals did not identify the significance of the pattern of missed appointments or avoidance of contact prior to Child J’s admission for failure to thrive;
• The immunisation of the child in August was done without apparent reference to practice notes that could have alerted the practitioner to the missed contacts and provided an opportunity for discussion.
• The failure to thrive was treated in isolation from other information that should have been available about this family.
• No discharge meeting was considered prior to allowing Child J to leave hospital. It is a missed opportunity to develop a plan of care to address Child J’s health needs.
• Thorough and appropriate medical examination did not identify evidence of injuries.
• Health professionals did not consider speaking with, or making a referral to, children’s social care services except when Child J’s parent was trying to prevent Child J’s admission to hospital. Having eventually agreed a referral was not made.
• Child J’s failure to thrive was treated primarily as a clinical presentation rather than a potential indicator of child neglect requiring multi agency co-ordination of information and assessment of need and risk.

Several of these themes are reflected in the national study of serious case reviews published by the Department of Children, Schools and Families (DCSF) in April 2008.

1.7 Good practice

There are examples of good practice. These include;

• The health visitor’s prompt and persistent action in October to secure Child J’s admission to hospital;
• When the skeletal x-ray identified injuries to Child J after his death prompt action was taken by the agencies;

1.8 Recommendations

43. The following recommendations to the Tameside Safeguarding Children Board are additional to the recommendations made by the PCT and Acute Trust. They are intended to improve recognition and reporting indicators of harm, ensuring missed appointment and avoidance of contact with professionals is recognised as a potential indicator of concern and needs follow up, improving support to families with additional needs, improving coordination of information and planning of services. The last recommendation highlights inadequacies in current post mortem arrangements that caused delay at the outset in identifying the injuries to Child J.

Recommendation one

The LSCB should ensure that all agencies providing services to children have explicit policies that clearly describe the responsibility of staff to follow up concerns about children. In particular the policies need to;

• Ensure that staff are clear about their responsibilities to act on concerns;
• Ensure that staff are aware of arrangements for making referrals or convening multi agency meetings and the purpose of doing so; and
• Ensure that all staff are clear about the purpose of communication in respect of what action they expect to be taken as a result.

Recommendation two

LSCB member agencies should ensure that all agencies providing services for children have explicit policies describing what action should be taken in the event of children not attending planned appointments or activities. The policies should include the process for assessing what level of concern is indicated and how appropriate action is taken. The LSCB should make arrangements for an audit of agency procedures to be completed and reported to the LSCB within six months.

Recommendation three

The PCT should ensure the policy for managing visits to children is reviewed following this SCR. In particular the review should ensure the policy describes clear steps for staff to take in the event of appointments being missed, correspondence or phone calls being ignored, or physical access to a house being denied. This should include ensuring all health staff supervising or providing health care services to the children are alerted. The policy needs to provide clear linkage to LSCB procedures and the local arrangements under the Common Assessment Framework (CAF).

Recommendation four

The LSCB should ensure the executive summary of this SCR is provided to the manager responsible for Children’s Centres and extended schools. In providing the summary the LSCB should request a response from that service concerning what policies are in place to establish contact and engagement with vulnerable parents with young children less than 2 years of age. Arrangements should be made for Children’s Centres to be made aware of vulnerable families and the criteria for midwives and health visitors to refer to Children’s Centres should be developed.

Recommendation five

The PCT should review the guidance for GP practices concerning the recording and sharing of information about vulnerable children. In particular the guidance should emphasise the duty and responsibilities of all health care practitioners in identifying and reporting concerns, and describe steps to be taken by healthcare staff in checking recent practice records to alert them to potential indicators of concern and the opportunities for discussing issues with parents and carers of children.

Recommendation six

The PCT should ensure that GP practices are required to undertake safeguarding training, including dealing with failure to thrive, and that this is monitored through the Standards for Better Health.

Recommendation seven

The LSCB should request further advice from the health trusts regarding future work plans and strategies regarding the management, storage and transfer of child patient information.

Recommendation eight

The acute trust should ensure all children admitted for failure to thrive or any other signs of neglect or harm are not discharged either until tests have ruled out non-organic reasons or a pre – discharge meeting has been convened that involves other agencies. This should be implemented within one month.

Recommendation nine

The acute trust should ensure that where a child has been or is failing to thrive, and non-organic harm has not been ruled out, the child will not be discharged until a second opinion is sought at the level of consultant. This should be implemented within one month.

Recommendation ten

The acute trust should ensure that all staff responsible for overseeing admission and discharge of children are capable of recognising the signs of neglect and abuse and have and know the procedures for seeking emergency protection of a child when necessary. This should be implemented within one month.

Recommendation eleven

The PCT as commissioner should ensure that a review of access to tertiary local paediatric pathology services is completed and a report provided with recommendations for completing future paediatric post mortems. This should be linked to SUDI procedures and the Rapid Response to Unexpected Child Deaths. This should describe timescales for completing post mortem tests and examinations that assist the police and other agencies in their enquiries under the SUDI arrangements. The PCT should be asked to examine whether it is possible to expedite elements of the post mortem (e.g. skeletal survey), in order to identify possible risk to other children.

Recommendation twelve

The LSCB should review existing training in respect of failure to thrive and neglect and commissions additional training as necessary. The LSCB Training and Development Sub Committee should undertake a review of the availability of training.

Reference

(1) Freedom of Information Act 2000 (Section 50) Decision Notice Date 23 August 2006.
(2) The Victoria Climbié Inquiry Report of an Inquiry by Lord Laming
(3) The ACPC was replaced by the Local Safeguarding Children Board