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Child Safeguarding Practice Review – An appreciative inquiry following an injury to an infant during the COVID lockdown summer 2020


  • Kate Stephens, Head of Service, Public Health Nursing
  • Shaeda Alam, Improvement Lead
  • Vivien Lines, Improvement Director

1.0 Introduction

1.1 Working Together 2018 requires safeguarding partnerships to conduct a Child Safeguarding Practice Review (CSPR) in some defined circumstances. The Devon Safeguarding Children Partnership (Devon SCP) decided to conduct a CSPR in relation to an infant, child A, who was injured (not fatally), during the first COVD lockdown, while in the care of the Local Authority in a Child and Parent Assessment Team (CPAT) placement. There were three principal reasons for this decision;

  • Risk of harm to infants in lockdown was a focus for the partnership which wanted to ensure learning from incidents was readily available to inform practice.
  • Child A’s parents had vulnerabilities (additional learning needs and a history of care) and they were open about their anxieties and uncertainties about their own parenting capacities. The partnership wanted to understand the ways in which their additional vulnerabilities, coupled with their openness and willingness to work in partnership, might have impacted on professional decision making.
  • At key points professionals made decisions which, with the benefit of hindsight, deviated from usual child protection practice. The partnership wanted to understand why that was so and whether any changes might need to be introduced to strengthen safeguarding practice in Devon.

1.2 Devon is trialling an Appreciative Inquiry (AI) approach to CSPR. AI is a strengths-based and systemic approach that seeks to understand the wider context in which professionals’ practice. AI was therefore adopted for this review. The review team identified a good practice example, with broadly similar features, to consider alongside child A to enable practitioners and reviewers to ‘compare and contrast’. The terms of reference and methodology are set out in appendix one.

2.0 Setting the scene

Child A

2.1 Child A was an 8-week-old baby, living in a child and parent assessment foster placement with her parents. In May 2020, she was presented to the GP by the foster carer with a torn frenulum.

2.2 Child A’s father had a history of trauma including sexual abuse and time in care and he had special educational needs. He was receiving support from a commissioned provider, Young Devon, as a care leaver. His GP had referred concerns about his depression, anxiety and history of trauma to Devon Partnership Trust, who had provided some interventions but discharged him in January 2020, when he did not attend assessment appointments. At this time, shortly before the baby was due, significant demands were being made of both parents by professionals.

2.3 Child A’s mother was known to another Local Authority’s Children’s Services as a child.

2.4 Child A was a first child and Child A’s mother attended a midwifery booking appointment when she was 13 weeks pregnant. The midwife noted that the couple had made enquiries about a termination as they were unsure whether they could look after a child. Child A’s mother attended all midwifery appointments.

2.5 The midwife contacted MASH during the week following the booking in appointment, due to the concerns expressed by the parents about their ability to look after their baby. It was agreed to respond with early help support and the midwife referred the parents to the local children’s centre who started working intensively with the couple from October 2019 providing targeted, personalised weekly sessions.

2.6 In December 2019, contact was made again by the midwifery service with the MASH highlighting her concerns about the couple’s ability to parent and to prioritise the needs of the baby once born. The decision was that support would continue on an early help basis.

2.7 In early February 2020, a third contact was made by the midwifery service to the MASH again expressing her concerns about the couple’s ability to manage the impending birth of their baby. A social worker was allocated who commenced an assessment. The midwife and the children’s centre workers met with the parents and extended family members to consider a plan for the baby’s birth. This meeting agreed that the parents could stay with the paternal grandmother pre-birth and once they returned home after the birth the paternal aunt could stay with the family as often as possible.

2.8 Concerns about the parents’ capacity to parent, the historical concerns about the extended paternal family and father’s own care history led to a plan to progress within the Public Law Outline (pre-proceedings) with consideration given to a parent and child assessment in parallel with family support being explored in more detail through a family group conference.

2.9 In early March, the parents were notified of the decision to operate within a pre-proceeding’s framework and a parent and child foster care placement was identified. In mid-March the parents met with the parent and child foster carers and it was confirmed that the baby would be placed with them through a S20 agreement and consequently would be deemed to be a child in care.

2.10 Child A was born on 22 March and the following day was transferred from hospital with her parents to a fostering placement from Devon’s Child and Parent Assessment Team.

2.11 In early May, Child A was observed to have blood in her mouth. The injury was not initially identified as being an indicator of physical abuse and was not responded to in accordance with agreed child protection procedures leading to a delayed response.

2.12 Following a child protection medical that confirmed a non-accidental injury the local authority initiated care proceedings. In the days after this, the parents decided to leave the placement.

Child B – Good Practice Example

2.13 Child B’s father had a 4-year-old daughter from a previous relationship who was removed from his care when 11 weeks old due to significant non-accidental injuries. During the care proceedings, findings were made against the mother of that child, with additional findings that the father had failed to protect and had colluded with the mother.

2.14 Based on the history the midwife made a referral to the MASH in the pre-birth period (September 2019). The MASH contact record noted the information that father’s previous child was removed and that the court did not find that he had caused the injury to his first child. As a consequence, no further action was taken in relation to the unborn Child B.

2.15 Routine ante-natal and post-natal care were provided by midwifery and health visiting services.

2.16 In June 2020, aged 20 weeks old, Child B’s mother contacted a GP at the local Minor Injuries Unit as she was concerned about swelling to the baby’s ear. The GP notified the social care Emergency Duty Team (EDT) and as there was no obvious explanation for the injury, the GP referred Child B for examination at a local hospital. EDT contacted Child B’s mother and advised her to take the child to the hospital paediatric unit, which she did. Further examinations were undertaken, including a skeletal survey and blood tests, and following this the Paediatric Registrar was conclusive about a non-accidental explanation for the injury.

2.17 Within 24 hours, enquiries were completed in accordance with S47 (Children Act 1989) including a strategy meeting being held and legal advice being sought. To ensure his parents were not able to remove him, Child B was made subject to police powers of protection whilst still in hospital. Within 5 days of the injury being known, children’s services applied to court for an Interim Care Order which was granted. Child B is currently in foster care.

3.0 Design and discovery – pre-birth

Child A

3.1 The initial discussions with professionals facilitated reflection on key aspects of the chronology; what had influenced how they had worked together and their decision making at key points. The discussions enabled professionals to reflect both on their practice at the time, given what they knew and thought at the time, as well as to reflect on information that wasn’t fully shared at the time and how this might have influenced their actions. Discussions were careful to identify learning that benefitted from ‘hindsight’.

3.2 Professionals reflected on the initial information sharing and decision-making processes. The midwifery service had made appropriate referrals. It was also agreed that the response to the initial MASH referral that the parents would be supported through an early help response was appropriate.

3.3 The midwife reflected that the parents knew they had a lot to learn, for example in response to their own lack of confidence in their parenting skills they had requested a simulated baby to assist their learning, but this resource was not available. All early help professionals reflected that whilst the parents engaged well, professionals were concerned about their ability to retain information, they felt they had used all the tools they had at their disposal at the time but were still not confident in the parents’ capacity to parent.

3.4 Midwives reflected that during this early help involvement pre-birth, professionals were frustrated that they did not have access to specialist learning disability advice or support because the parents didn’t have a diagnosed learning disability. Instead, the midwife accessed specialist parenting support materials which she found to be outdated and limited in supporting work with the parents to be undertaken in a way that was sensitive to their learning needs and consequently effective.

3.5 The second referral from the midwifery service, when more significant concerns started to be identified about the parents’ capacity to learn how to parent appropriately, was good practice and timely. Professionals reflected that this referral was clear and presented enough information for the MASH to accept it as a referral and for a social worker to become involved to complete a parenting assessment pre-birth.

3.6 Professionals reflected on why the referral had not been accepted by MASH at the time. MASH staff reflected that their decision was based upon the parents engaging well with early help and the safeguarding concerns in the referral were not articulated sufficiently clearly. The background checks undertaken by the MASH did not establish the historical information about the parents or establish that professionals and agencies including the GP, Devon Partnership Trust and Young Devon had relevant information about the father.

3.7 Midwives and children’s centre staff reflected that the decision not to challenge the MASH decision at this point was in part because at the time they weren’t aware of both parents’ historical involvement with services. In addition, they viewed the social worker as the expert in determining thresholds and access to statutory services. Further, midwifery staff felt there were no mechanisms to speak to the MASH to understand the decision they had made or to challenge it.

3.8 As the birth became more imminent, the midwives and children’s centre staff became more concerned about the parents taking their baby home alone and whether the wider family support available was sufficient. They also reflected that there had been considerable discussion between them about thresholds and whether the case should be re-referred to MASH, including reviewing the evidence held by the children’s centre.

3.9 The midwife recalled being concerned about the couple’s capacity to receive and process information given their learning needs. She was concerned that the unborn baby was at risk of neglect as the parents had not demonstrated that they understood how they would respond to and meet the basic needs of their baby. The midwife felt that their apparent learning needs risked them not being able to prioritise the needs of the new-born baby, despite the support that the children’s centre had been providing.

3.10 The midwife reflected that in this context she made a further referral to MASH in order to trigger a social work assessment as she felt it was needed to inform clear decisions about the level of supervision and support the couple required to parent their baby safely. Professionals agreed that a further referral to the MASH was appropriate at this point and that allocation of a social worker was the right outcome.

3.11 The Children and Families Social Work Team Manager reflected that their involvement came very late, a month before the baby’s expected due date, which provided limited time for comprehensive pre-birth assessments and informed planning for the baby’s birth. Children’s social care also reflected that there was limited information available to them at this point about the parents’ learning needs or backgrounds.

3.12 In summary, professionals reflected how information sharing at this early stage had not enabled key background information to be known and shared effectively to inform early and appropriate decision making.

3.13 Professionals agreed that the initial early help and family support interventions were appropriate and of a good standard but would have been more effective had professionals had access to advice and support in working with parents with additional learning needs.

3.14 In addition, practitioners reflected that culture and practice impacted on professional engagement in and challenge to the MASH decision making.

4.0 Design and discovery – post-birth

Child A

4.1 Practitioners reflected on child A being discharged from hospital with her parents to a child and parent fostering team placement (CPAT).

4.2 The CPAT placement was agreed to have been made as a result of there being significant concerns about parental capacity and inadequate time to complete a pre-birth community-based assessment, rather than there being explicit concerns that the parents presented an immediate risk to the child.

4.3 Not all professionals were directly involved in the decision to place in a CPAT placement and reflected that they were not entirely clear what this involved, in particular the level of supervision that was offered. Health professionals reflected that they assumed the placement offered 24/7 supervision.

4.4 The placement was in a different geographical area and so health visiting responsibility changed at the point of placement. The new health visiting service described receiving only a brief transfer note containing only an address and without information about the parents’ circumstances or the reason for CPAT.

4.5 The start of the placement coincided with the first period of national lockdown as a result of CV-19 which impacted on working arrangements.

4.6 The CPAT worker reflected that it is usual for them to commence their assessments before the placement is made. On this occasion, the placement was made with limited pre-placement assessment or planning and the set-up meeting between the social worker and the foster carers was held virtually. However, managers from the CPAT reflected that the foster carers were experienced in working with parents who had learning difficulties and they were satisfied that there was close supervision of the parents in this placement with good support.

4.7 The parents were discharged from the hospital to the placement on the day the first national lockdown restrictions commenced and the foster carers reflected that, as a result, usual practices, including a pre-placement meeting between the carers, the parents, the child’s social worker and the CPAT worker, did not take place. The foster carers were unable to attend the discharge planning meeting in the hospital or meet with the parents in the hospital prior to placement instead they collected the parents and their baby from outside the hospital following discharge. In addition, the placement agreement between the parents and foster carers was undertaken entirely remotely. As a result, the foster carers felt they were provided with limited information regarding the couple and the extent of their learning needs at the start of the placement.

4.8 The foster carers recalled that the parents arrived with no belongings, clothes, baby items or food and this was problematic given the lockdown. The foster carers acknowledged that much of this was unavoidable in the circumstances. This can only have been an extraordinarily disorienting experience for already very vulnerable and anxious first-time parents.

4.9 During the initial weeks of the placement, professionals described their contact with the carers and parents as being virtual, apart from the health visitor who made a home visit in early April. CV-19 prevented the parents being seen in the placement by the CPAT worker and the children’s social worker and their ‘visits’ were undertaken via video calls. Consequently, professionals were relying on the information provided by the foster carers in their daily and weekly records which the foster carers described sharing with the CPAT worker and the children’s social worker by email.

4.10 Despite having a good relationship with the parents, the foster carers reflected that the parents struggled to learn through their role modelling of parenting techniques. They felt that whilst the parents could follow a routine and instruction they had difficulty in retaining information and self-initiating care, and as weeks went on continued to require a high level of supervision and instruction and were demonstrating some frustrations at the baby’s crying and inability to engage emotionally with her.

4.11 The foster carers noted that they provided some oversight of the parents’ care of their baby on a 24-hour basis for the first three weeks of the placement. However, they weren’t able to watch all of the interactions between the couple and their baby all of the time. They used a baby monitor (listening device) placed in the parents’ room which, for example, enabled them to monitor the parents’ response to the baby crying. They also had a camera positioned on the baby’s cot which they could view when they logged into their mobile phones. Otherwise they would be able to observe the parents fully by going into their room which initially they would do fairly frequently.

4.12 After the initial three-week period the level of supervision/monitoring reduced including agreement that the parents had more unsupervised time with the baby, including going out on their own for an hour or two at a time.

4.13 Professionals reflected that for these first few weeks, despite some continuing concerns about the parents’ capacity to learn, the placement was viewed positively; the parents were engaged and willing to learn and consequently the focus of the plan was on supporting them to develop the parenting skills needed through coaching and modelling by the foster carers. The first child in care review was held virtually and the focus was described as being to support the baby to remain with her parents. Professionals agreed that the parents were not perceived as presenting a risk to the baby.

4.14 Professionals reflected that this focus on help rather than protection was reinforced by their understanding that the placement provided supervision of the parents with the baby which ensured she was safe.

4.15 However, professionals involved agreed that during the initial weeks of the placement they continued to be concerned about the parents’ capacity to learn. Professionals agreed that these concerns escalated around the six-week point. CPAT social workers reflected that they had alerted the children’s social worker of concerns highlighted in the foster carer’s records about the parents’ ability to retain information and the baby’s father becoming stressed with the baby’s crying. Health professionals agreed that whilst in the CPAT placement the parents’ undiagnosed learning difficulties continued to impact on their ability to understand basic instructions and to retain information.

4.16 The group reflected that, through this time, communication between professionals was mostly by email rather than by telephone and professionals were only meeting virtually. They felt that this impacted on the quality of their interactions and decision making.

5.0 Design and discovery – discovery and response to the injuries

Child A

5.1 When the foster carers first noticed blood on the teat of the baby’s bottle and in the baby’s dribble, they described it as ‘miniscule’ and reflected that they had discussed with each other whether they should raise this with the GP but given the context of the ongoing pandemic and difficulties in trying to get through to the GP surgery via the telephone they decided not to. They took photos of the injury and, as it was a Sunday, they agreed with the parents that they would speak about it with the health visitor on Monday and recorded the incident in their daily record for the CPAT worker.

5.2 The foster carers reflected that they considered the blood to be a minor injury in the baby’s mouth maybe caused in feeding, that they had previously noted that the parents were not feeding the baby correctly and had advised them how they should do this. The foster carers advised that at this point their response was influenced by not considering the possibility that the parents had harmed the baby maliciously.

5.3 A few days later the foster carers again observed blood in the baby’s mouth. They spoke to the CPAT worker later that day who advised they take her to the GP. The following morning the social worker and the health visitor (having taken advice from the Named Nurse) also agreed with the plan to take the baby to the GP that day. Due to CV-19 restrictions only one person was allowed to attend the surgery, so the foster mother took the baby for the appointment that afternoon following which the GP updated the social worker.

5.4 The GP knew the foster carers well and had no concerns about their care. He was alerted by the foster carers to a concern that a parent may have put their finger in the baby’s mouth. There was no indication to the GP that the child could be at risk. He examined the baby, identified a torn frenulum, notified the social worker accordingly and recalled discussing with her whether a paediatric examination should be sought. The GP described the social worker as being uncertain and he left it with her that she would discuss with her manager.

5.5 The GP had not encountered a torn frenulum previously in his career and was not aware that a torn frenulum was a definitive indicator of physical abuse.

5.6 In the email update following the consultation, the GP was conclusive about the injury, that the baby had a lower lip frenulum tear but was not explicit about it being a child protection concern. Their note to the social worker following the appointment indicated that the baby was considered to be in a ‘place of safety’ in foster care.

5.7 The foster carers felt that they were informed about non-accidental injuries in non-mobile infants as they had accessed child protection training. However, they agreed their response to the injury and failure to consider a child protection response was influenced by the parents’ limited parenting capacity and the GP’s initial response. They reflected that had the injury been a bruise they would have considered a non-accidental explanation more readily.

5.8 The social worker and CPAT workers reflected that when they learned that blood had been found in the baby’s mouth, they were initially not unduly alarmed. They reflected that the GP appointment was arranged and that this was felt to be an appropriate response, rather than a strategy meeting and a child protection medical being arranged as it should have been in these circumstances, as they were aware of concerns about the father feeding the baby roughly and placing his finger into his mouth.

5.9 The health visitor felt that she was clear the bleeding was a concern but that, following discussion with their Named Nurse, the advice was to continue with the GP appointment.

5.10 Most professionals felt they had an acceptable explanation for the injury and in the context of the parents being engaged and trying to learn and the baby being placed in what was perceived to be a ‘safe’ environment, did not initially consider a child protection response. This appeared to include the GP who following their consultation noted the child as being in a ‘place of safety’ with the foster carers and so was not concerned about their return home.

5.11 The social worker reflected that as a child protection investigation was not initiated following the GP examination, she remained uncertain about the nature of the injury. The social worker recalled being influenced in her judgement about the appropriate response by the GP not clearly stating a non-accidental injury following their examination and given this the social worker reflected that she didn’t feel that she needed to inform her manager as she did not judge this to be a child protection issue.

5.12 The following day, on becoming aware of the outcome of the GP examination, the team manager arranged a strategy meeting which led to a child protection medical, a more definitive view from the paediatrician that the injury was caused non-accidentally and a more protective response was put in place, including the foster carers taking over the care of the baby.

Child B – Good Practice Example

5.13 In comparison, in the case of child B, the GP who was first notified of the injury immediately recognized it as being an indicator of physical abuse, due to its location and the child being non-mobile, and immediately notified children’s social care in line with established procedures. This led to a child protection medical being sought promptly. This confident initial response was then reinforced by the definitive diagnosis of a non-accidental injury by the paediatrician.

5.14 As a result, professionals reflected that initial decisions were made in a timely way and children’s social care took timely and appropriate action to ensure that the child was not returned to the parents’ care.

5.15 However, it is important to question whether, in the MASH decision making in relation to Child B, enough weight was given to the finding of fact in relation to Child B. The father was found not to have caused the injuries to the earlier child but he was found to have failed to protect and to have colluded with the mother.

5.16 In the two cases we can see that it isn’t helpful to label practice good or bad in a binary way; there are significant strengths in some aspects of practice with Child A, and some questions to be examined in respect of practice in Child B.

6.0 Parental engagement

6.1 The parents of both child A and child B were contacted in relation to this review when the care proceedings following the concerns had concluded.

6.2 Child A’s parents were contacted in relation to this review via their solicitor but have not yet been able to engage due to the impact of the care proceedings which have only recently concluded, on them. They have been informed that this review has taken place and we have offered the opportunity to meet if they wish to do this prior to publishing this report.

6.3 Child B’s mother provided valuable observations of her experience of the child protection investigation and how professionals supported her through this. She reflected that at the time she understood what was happening and why, she felt the GP described things well when initial concerns were identified, and a child protection response deemed necessary.
6.4 However, she found the experience of the medical in the hospital very ‘scary’, recalled a difficult conversation with an emergency social worker but that the medical staff were very supportive and very clear with her about what was happening through the process.

6.5 She wish that an alternative could have been considered to her child being removed from her care following the incident. However, contact was maintained well. She also experienced several changes of social worker through the process which were not always handled smoothly.

6.6 She was informed that the review will be published and would like her social worker to support her to access it when it is.

6.7 Child B’s father was notified of the review, but we were unable to establish contact with him to discuss this in detail.

7.0 Analysis: reflections of the review team

7.1 Exploring the two cases highlighted key elements of good practice and developed a better understanding about the conditions that enable this to be achieved. Engaging staff in a reflective and appreciative process was valuable for both their individual learning and learning about the wider system.

7.2 The importance of thorough and early information sharing between professionals and thorough, early assessment to inform early decision making was highlighted. As an example, early help colleagues were unaware of the GP’s significant concerns about child A’s father’s mental health and the work of DPT and Young Devon. The GP and DPT were unaware of the pregnancy and the substantial early help work that was underway.

7.3 The enquires undertaken for child B were based on timely and effective information sharing about parental history. In contrast, key decisions about the response to child A were made without significant information having been shared effectively.

7.4 In the case of child A, the midwife acted in a timely way in relation to her early concerns but decision making and response to the early referrals to MASH were made without full information gathering and access to key background information about the parents.

7.5 Some strengths were seen in the way professionals worked together, yet professionals were not sufficiently confident or enabled to provide appropriate challenge at key points, including following the second MASH referral.

7.6 Lack of detailed communication to the referrer of the decision following the referral appeared to impact on their confidence in challenging the decision. This has been identified in other reviews as leaving professionals feeling ineffectual, powerless and uncertain as to what is happening to a child [1].

[1] The Missing Assessment Domain, J. Howorth, 2003 (Cleaver et al, 2004; Ferguson and O’Reilly, 2001; Holland, 2004).

7.7 Further, professional dynamics also appeared to influence professional challenge. Established relationships between professionals are important to effective professional challenge. The children’s centre worker and midwifes said that they would have felt more able to challenge if they had a named contact in the MASH. They were not aware of the details of the health professional in the MASH.

7.8 For child A, the absence of full early information sharing and acceptance of the MASH response to the referrals led to a continued early help offer which did not effectively respond to the parents’ additional learning needs and histories, draw in more expert professionals to inform the work with them or communicate clearly the level of concerns that existed to either the parents or the professionals involved.

7.9 Not all professionals were aware of the interventions that had been tried by services in the pre-birth period and of the full chronology. Key information relating to the parents’ backgrounds was not fully shared between professionals until after the child protection incident. Effective ‘team around the family’ arrangements were not helped by the emerging context of the pandemic and its impact on working arrangements.

7.10 The MASH referral to social care in February 2020 included that DPT had recently been involved with the father but the information about their involvement had not been explored fully by the social worker during their assessment prior to or during the CPAT placement and consequently the concerns about the father’s anxiety, depression and mood swings were not known at this time by the children’s social worker, CPAT worker or foster carers.

7.11 More effective information sharing and an earlier ‘step up’ from early help to a social work led pre-birth assessment, informed by an early assessment of the parents’ cognitive functioning, would have better informed an appropriate plan for the baby’s birth at an earlier point.

7.12 Professionals involved at the early help stage were clear that they had concerns about parenting capacity however, in the context of two parents who were engaged and presenting as wanting to learn, professionals continued to be optimistic about the potential for child A to remain with her parents.

7.13 The recently published first annual report on the Child Safeguarding Practice Review Panel highlighted “optimism bias” frequently comes from weak risk assessment and poor information sharing” [2]. In cases where parents with learning difficulties engage and work well with authorities to ensure they can keep their children, there is a risk of optimism bias which results in unrealistic hopes that parents can safely parent their child.

7.14 In the case of child A, professionals involved with the case, pre-birth and post -birth had “an over-optimistic wish to keep children with their parents which had led to the dismissal of overwhelming evidence to indicate this was not in the child’s best interests” [3].

7.15 Booth et al (2004) also found that parental compliance comprises of three closely related characteristics: an acknowledgement of the seriousness of the workers concerns (insight); a willingness to cooperate in addressing these concerns; and a commitment to change [4]. Child A’s parents presented with all these characteristics and as a result they were not clearly identified by early help professionals as a potential safeguarding risk to the child. This view of the parents may have influenced decision making by MASH and contributed to the absence of professional challenge to this.

[2] The child safeguarding practice review panel: first annual report, DfE 2020

[3] The child safeguarding practice review panel: first annual report, DfE 2020

[4] Booth et al. (2004) Temporal Discrimination and Parents with Learning Difficulties in the Child Protection System. British Journal of Social Work 36(6)

7.16 The decisions to move to a pre-proceeding’s framework and for a parent and child fostering placement to be provided indicate a recognition of seriousness as these resources are deployed only in circumstances which merit them. However, these decisions were not made in a multi-professional forum and this would have improved understanding about the level of concern that existed, the nature of the placement and the level of supervision provided.

7.17 Research has identified a mode of thinking that people engage in when they are deeply involved in a cohesive group, where members’ striving for unanimity overrides their motivation to realistically appraise alternative courses of action. Eraut (1994) identified that professionals will make sense of information in different ways and the way that information is shared or referred varies in terms “of the information shared as significant, how the information is shared and with whom” [5].

[5] Eraut, M. (1994) Developing professional knowledge and competence. London, The Falmer Press, pp.49

7.18 Professionals acknowledged that the injury to child A did not lead them to reconsider their assessment and direction. The judgement of the foster carers was influenced by their over empathising with the parents combined with anxiety around the impact the pandemic was having on the time constraints for professionals around them.

7.19 The multi-disciplinary team did not collectively consider the possibility that child A had suffered significant harm, and this influenced the approach to and outcome of the appointment with the GP.

7.20 The GP did not have full information about the baby’s current care prior to the assessment of the injury. He knew the foster carers well and so had a perception that the child was safe.

7.21 He confirmed a torn frenulum, yet as a result of both the GP and the social worker not identifying this to be an indicator of physical abuse child A was returned to the care of her parents without a child protection medical being arranged and this was only arranged following the intervention of the social work team manager the following morning.

7.22 In contrast to child A, child B’s injury resulted in child protection procedures being followed confidently and in a timely way as the professionals involved were open to the consideration of physical abuse being an explanation for the injury. A child protection medical was sought appropriately leading to a confident safeguarding response being put in place in a timely way. Effective communication and decision making were influenced by a confirmed diagnosis, which set into motion the statutory practice processes. The initial medical was undertaken by a hospital paediatrician and arguably their greater experience in assessing injuries enabled a clearer outcome.

7.23 The incident to child B occurred a few months after child A’s by which time working practices had adjusted to the context of COVID-19.

8.0 Conclusions

8.1 Children’s social care were able to give practice examples of how findings from the earlier rapid review had already informed their individual work with children as a result of having been included in the “close the loop” approach following the rapid review. However, this was less evident for other professional groups.

8.2 Practitioners reflected that they found the appreciative inquiry approach respectful and thorough. GP colleagues were unable to participate in the group reflective discussions and other practitioners reflected that their attendance would have added to the learning in both cases.

8.3 All professionals involved reflected that the appreciative inquiry approach added value to local learning as they were more fully engaged in a reflective process and in the identification of learning. At the ‘close the loop’ session practitioners involved reflected on their experience of the Appreciative Inquiry and reflected that they had made some changes in practice as a result of their learning.

9.0 Recommendations

9.1 During the reflective discussions, professionals involved were given the opportunity to identify their thoughts about practice improvement in response to the practice issues identified in this case. Their reflections have informed the development of these recommendations.


1. Review operating procedures to ensure clarity about the completion of background checks in response to referrals.

2. Publicise mechanisms for professional challenge to MASH decisions across the partnership.

3. Health representative in the MASH to meet with midwifery and health visiting managers to clarify role and communication routes.

4. Education representative in the MASH to meet with children’s centre managers to clarify role and communication routes.

Early help

5. Review arrangements for ‘stepping up’ cases from early help and the potential role of early help triage in this.

Learning disability

6. Strengthen relationships between early help and adult learning disability services and agree the role of adult learning disability services in early help triage.

Care leavers

7. Ensure the current review of the local offer for care leavers confirms the local offer for care leavers who are parents.

8. Develop the vulnerable pregnancy pathway to explicitly include care leavers, mothers or fathers, as eligible for access to the pathway for an enhanced support offer.

CPAT placements

9. Consider including wider multi-agency partners in CPAT planning and review meetings.


10. CPAT to ensure information sharing takes place with GPs when child and parent placements are made in their area.

11. Continue to prioritise child protection training for GPs.

Appendix A

Terms of reference

These were agreed as:

  • To use an Appreciative Inquiry approach to compare practice in two cases to understand why professionals took (or didn’t take) actions at key points in the cases.
  • To better understand practice and decision making relating to children aged under 1 where physical abuse is a concern.
  • To engage partners in reflective discussions in order to understand the rationale for decisions made at key points in the cases and identify learning about best practice.
  • To identify key learning and inform local improvements to how professionals work together.
  • To gather specific examples of when practice has worked well so that these conditions can be built on in future arrangements.
  • To develop SMART recommendations for improvement through local implementation.


A review was undertaken using an Appreciative Inquiry approach to compare and reflect on practice in two cases. Practitioners and managers involved in both cases were brought together for facilitated reflective discussions using the ‘6D’ approach shown below.

A diagram of the 6Ds

Two cases were compared. One case had been subject to a Rapid Review and had been identified as having learning about responding to children under 1 experiencing physical abuse. The second comparative case had similar features, but practice was in accordance with expected procedures. The 6D approach was used to facilitate a reflective discussion with practitioners in each case about why practice in one case was judged to be good (in accordance with established child protection procedures) whereas the other had not adhered to established best practice expectations and learning was identified.

The Appreciative Inquiry approach followed the methodology that the Devon Safeguarding Children Partnership had developed with Research into Practice as part of an earlier pilot. Reflective sessions were held with all of the professionals who had been involved in the cases; social workers, children’s centre workers, health visitors, midwifes, and family practitioners. Separate meetings were held with child A’s’ foster carers and the GPs involved.

Both children remain open to statutory services and are currently within care proceedings. While the full model should seek and consider the views of parents, this was not possible for this review due to ongoing court proceedings on both children.

Professionals were organized as follows:

  • Child A – Group 1 was made up of practitioners involved pre-birth and Group 2 of practitioners involved post-birth. These were determined to be two distinct phases in the family’s relationship with services.
  • Child B – professionals who were involved were brought together in one group.

Each group met twice for a facilitated reflective discussion about practice and a third time to determine and agree conclusions. All those involved shared findings and agreed key points of learning across the system.

While professional attendance for child A was good, there was more limited practitioner attendance in Child B’s case discussions which impacted on the ability to undertake a comprehensive comparison of practice between the two cases. However, valuable learning was established.

Each multi-agency group session was jointly facilitated by:

  • Kate Stephens – Head of Service, Public Health Nursing; and/or
  • Shaeda Alam, Improvement Lead, Children’s Social Care.

Colleagues from The National Probation Service and Devon and Cornwall Police Service observed each session, took notes and contributed to the post discussion reflections.