1. Introduction
1.1 Working Together 2018 requires safeguarding partnerships to conduct a Child Safeguarding Practice Review (CSPR) in certain, defined circumstances. The Devon Safeguarding Children Partnership (known at the time of the review as the Devon Children and Families Partnership) decided to conduct a CSPR following the death of Child Jody (pseudonym).
1.2 There were three main reasons for this decision:
- Risk of harm to infants is a focus for the Partnership which wanted to ensure learning from incidents was readily available to inform practice.
- The Partnership is also focusing on why fathers / male partners are not more fully included or considered in the wider safeguarding assessments.
- 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 and if any changes might need to be introduced to strengthen safeguarding practice in Devon.
1.3 It was intended that the review would use the circumstances surrounding the death of Child Jody to try to understand why the lessons learnt from similar reviews, nationally and locally, had not led to a change in practice. The review therefore considered the issues arising out of Jody’s death in that context rather than focusing solely on Jody. The report provides a brief summary of Jody’s life by way of an introduction to the issues raised in other local and national reviews. The learning specific to Jody had already been identified and actions taken following an earlier rapid review.
1.4 The failure to incorporate the lessons learnt into practice is not just a local issue. It has also been a feature of national review, which was one of the reasons for the national panel publishing its thematic report ‘The Myth of Invisible Men’ (September 2021). Devon SCP is therefore not alone in seeking to understand how best to implement and sustain changes in practice.
1.5 An Appreciative Inquiry (AI) approach to CSPR was adopted for this review. It is a strengths-based and systemic approach that seeks to understand the wider context in which professionals’ practice. The terms of reference and methodology are set out in Appendix A.
2. Context
2.1 Child Jody was the youngest of three siblings. They were born in July 2022 at 35 weeks in an unplanned home birth. Mother was believed to be under the influence of cannabis at the time; the ambulance service had to break down the door to gain access. Mother and baby were taken to hospital.
2.2 As a result of the concerns identified at the time of mother’s admission to hospital and in the light of the known poor relationship between her and the baby’s father, a Strategy Meeting was held. A Section 47 enquiry commenced. The strategy discussion decided that mother and baby needed to stay in hospital for period of observation pending a discharge planning meeting.
2.3 The following week, a Discharge Planning Meeting was held at the hospital. Whilst Jody was fit for discharge, Jody subsequently developed jaundice and needed to remain in hospital. This appeared to be the cause of frustration to their mother; hospital staff raised concerns about mother’s aggressive behaviour towards the father and Jody. Mother and baby were discharged from hospital a couple of days later.
2.4 Subsequently, all the children were seen in the family home by a social worker and by a midwife (accompanied by her assistant). No concerns were reported, other than midwife questioning whether Jody had had jaundice due to their colour.
2.5 Early the following week, Jody’s father sent the social worker a message, advising that there was some sickness in the family. In view of this and asking that the planned visit be rescheduled for the next day.
2.6 On the following weekend, Jody’s mother called an ambulance around 9am on the Sunday morning. She reported she found Jody unresponsive and said they had a purple face. Mother attempted CPR as advised by 999-call handlers. The paramedics also attempted CPR when they arrived. Sadly, Jody was pronounced dead at the hospital at only 16 days old.
2.7 At the time of Child Jody’s death, the Section 47 enquiry had not been completed.
2.8 Mother and father were arrested and were subject to a criminal investigation and interview. It was established that the father was not present at the time of the death. As a result, mother was released with bail conditions to not have contact, unless supervised, with any child under the age of 18 years old.
3. Background
3.1 The family had been known to children’s services since the birth of Jody’s eldest sibling in 2017. Jody’s mother had herself been in care and had extensive involvement with children’s services.
3.2 There were also several concerns relating to the children’s father. He had served a prison sentence for firearms offences, had a history of domestic violence and a previous child had been removed from his care. The relationship between the parents was known to be volatile. During periods of separation including when the father had been serving a prison sentence mother was known to have been in relationships with two other men who also presented with significant issues and drug and alcohol dependency.
3.3 The oldest child was at one point subject to a Child Protection Plan which was subsequently stepped down to a Child in Need Plan. There were continuing concerns, and a lack of clarity, as to whether Jody’s mother maintained a relationship with the partner who had triggered the safeguarding concerns.
3.4 Jody’s mother told professionals she had resumed a relationship with her oldest child’s father with whom she then became pregnant with Jody. Following the baby’s birth, the relationship between the parents which had always been volatile broke down and Jody’s father left the family home.
4. Reflections on practice relating to Child Jody
4.1 In April 2022 a CIN assessment was completed following concerns expressed about mother’s then partner. The assessment did not address the unborn baby. Given the historical and current concerns, including the fact that the parents had resumed their relationship and that mother was at that point living with someone who was not the father of the unborn child and about whom there were concerns, this should have been a multi-agency pre-birth assessment conducted within a safeguarding framework.
4.2 There was a lack of professional curiosity evidenced by the agencies involved which meant that appropriate services were not offered, and concerns minimised.
4.3 A full family history was not used to inform children’s services planning for Jody including discharge planning where the family history along with mother’s behaviour to both her partner and the baby could have raised an alarm.
4.4 Mother smoked and was known to use drugs but was not referred to the complex midwifery team or offered smoking cessation advice.
4.5 Given mother’s history and what was known of the family history the vulnerable pregnancy pathway should have been considered.
4.6 There is no evidence that the day-to-day experience of Jody’s siblings was considered in assessments. The police reported that the children appeared to be unperturbed when they were called out to incidents of aggression between the parents suggesting that this was a regular occurrence.
4.7 A mark on Jody was observed by the midwife but not followed up as a safeguarding issue.
4.8 Safeguarding training for midwives was not up to date.
4.9 Perinatal mental health could not be triaged due to having insufficient information.
4.10 The strategy meeting held after Jody’s death did not include all relevant agencies. For example, there was no one from midwifery services, no manager from social care and no one from education given that the eldest child was of school age.
4.11 There were some areas of good practice in relation to Child Jody:
- Appropriate action was taken to safeguard Jody’s siblings following their death and court proceedings were instigated.
- Hospital staff were attuned to mother’s behaviour while in hospital with Jody and raised appropriate and proportionate concerns about this.
- All three children were seen at home on three occasions by the social worker after Jody was discharged from hospital.
- All three children were seen at home by a midwife.
5. Reflections on national and local practice reviews
5.1 Recent national reviews:
- Lack of timely and appropriate information sharing
- Dealing with each referral as a separate episode and failing to consider all the known information about each member of the family (including any partners) both current and historical.
- Failure to appreciate the impact of domestic abuse on children in the family.
- Lack of understanding of the child’s daily life, limited or no direct work, failure to speak to or consider the views and concerns of wider family members who know the child.
- The impact of assumptions and bias when working with diverse communities
- Working with families who are reluctant to engage, recognising and dealing with parental avoidance.
- Missed opportunities for critical thinking and challenge between agencies.
5.2 Local Reviews
- The terminology used in recommendations is non-specific rather than directive.
- Poor practice in relation to information sharing.
- Pre-birth assessments are not sufficiently robust or multi agency.
- Failure to recognise the heightened risk of domestic abuse during pregnancy. This is not routinely asked about during ante natal screening.
- Lack of parental consent should be considered and analysed in terms of risk and trigger professional curiosity.
- Transfer of cases should include a clear comprehensive handover of information including a written chronology of key events and decisions.
- Assessments lacked key information to inform decision making.
- Over reliance on self-reporting by parents, lack of professional curiosity
- Cross border checks not completed when a family moves from outside the council.
- Lack of multi-agency work and triangulation early help or specialist services of information.
- Follow up reviews of children’s health and development not completed.
5.3 Positive Recommendations from local reviews
- Ensure “stop and review” process is instigated for all long-term cases.
- Agencies must clarify what would trigger action e.g., child not brought to appointments or attending school.
- Practitioners need to consider and record their rationale for considering whether a child’s needs are being met, familiarising themselves with the threshold tool.
- With parental consent the local authority will conduct an assessment and if the threshold is met organise a multi-agency meeting to draw up a child in need plan.
- If parents refuse consent, they will either be offered early help and the ongoing support of specialist services or, if it is considered that the child is at risk of significant harm, an assessment will be carried out as a S47 child protection investigation.
- The commitment of all partners to CIN plans and meetings and is essential.
- Partners must hold each other to account.
- Every agency needs to ensure that practitioners and managers understand how to problem solve with partners and escalate more formally if necessary.
- When a family moves into the area historic information must be sought from the previous authority.
5.4 Barriers to communication and learning:
- Agencies all have different IT systems and do not have access to each other’s records.
- High staff turnover.
- Capacity issues.
- Inexperienced staff not understanding how to escalate or chase information.
- Poor recording.
- Anxiety around consent and if this is needed to share information.
- Internally, the volume of information not reaching practitioners, not embedded.
- Externally, the lack of consistent working relationships between professionals due to staff turnover and working practices.
- Concerns around the relationship with health and police lack of understanding of roles.
- Lack of involvement of GPs can be a barrier to information sharing.
- Agencies poor or slow at sharing information.
5.5 What can be done differently in the future to make positive, permanent changes? How can we minimise barriers for our workforce / frontline professionals?
- Networking and building relationships.
- Rolling programme of mandatory multi agency training
- Making information more accessible and easier to absorb
- Improving understanding of the different roles of agencies in relation to safeguarding
- Support and challenge to practitioners
- Regular meetings between CSC and midwifery
5.6 Some practical solutions:
- Safeguarding information request for to be sent to GPs to elicit relevant information on both parents.
- Midwives and Designated Safeguarding Leads in schools need to have supervision.
- Monthly partnership working with Early Help needs to be more widely advertised.
- Devon SCP policy on escalation needs to be widely shared.
- Organisational charts shared and updated monthly.
6. Key lines of enquiry
6.1 Explore if partners cascading and embedding learning from other LCSPRs and Rapid Review.
6.2 Explore if managers have understanding of risk, including parental and other adult’s histories in relation to assessment and planning for children.
6.3 Do all partners have robust processes /systems to ensure that the experience of babies and young children are captured by professionals working with them and contribute to risk assessment.
6.4 Examine communication between agencies where there are concerns antenatally, including the function of the Vulnerable Pregnancy Pathway.
6.5 Explore the understanding and application of policies and procedures in relation to safeguarding unborn, and new-born babies in midwifery services.
6.6 Do partners adequately assess and manage the vulnerabilities for children considering parental risk factors?
7. Conclusions
7.1 Practitioners reflected that they found the appreciative inquiry approach respectful and thorough. GP colleagues were unable to participate in the group reflective discussions.
7.2 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. Practitioners involved reflected on their experience of the Appreciative Inquiry during their final session and reflected that they had already made some changes in practice as a result of their learning.
8. Recommendations
8.1 Multi agency mandatory briefings twice a year on lessons from case reviews, how that translates into practice and understanding of roles and responsibilities. The briefing should also include a review of the actions arising out of previous briefings.
8.2 Section 11 audits should include a focus on the implementation of actions arising out of case reviews.
8.3 For CSC concentrate on front line practitioners and Team Managers
- What should be included in a S47/ pre-birth assessment?
- When to undertake a pre-birth assessment
8.4 For first line managers in all agencies
- Emphasise their role as gatekeepers of good practice.
- Supervision must include guidance and challenge.
8.5 Child Protection Conference Chairs should quality assure all reports to conferences and feedback to managers when there are concerns re quality of social work assessments.
8.6 There should be an audit of the use of the vulnerable pregnancy pathway including the decision about level of support / referral to social care.
8.7 All partners including midwives, health visitors and GPs to complete the Domestic Abuse enquiry question as recommended by NICE guidance. Midwifery assessments should take into account the unborn and the father / mother’s partner / members of the household and if they can’t include the father, it should be flagged as an issue to be followed up post birth by the HV.
8.8 Where an assessment of need / risk is being undertaken and it is established that the woman is pregnant the assessment must include reference to the unborn
8.9 Mandatory Safeguarding induction to be provided on a multi-agency basis; and there should be annual refreshers.
8.10 Children’s social care should ensure that all relevant agencies are invited to strategy meetings.
8.11 Devon to establish a data sharing warehouse to share basic information between agencies.
Appendix A
Terms of reference
- To use an Appreciative Inquiry approach to explore current practice and review processes to understand why similar recommendations continue and learning is not embedded.
- To engage partners, in particular Managers/Leaders, in reflective discussions in order to understand learning processes/resources.
- To identify key learning and inform local improvements to how professionals work together.
- To develop SMART recommendations for improvement through local implementation.
- Focus on whole system, at manager level, not individuals/agency practice issues.
Methodology
A review was undertaken using an Appreciative Inquiry approach to reflect on practice. Practitioners and managers involved in the case were brought together for facilitated reflective discussions using the ‘6D’ approach.
- The 6D approach was used to facilitate reflective discussion with practitioners based on specific questions and answers in multi-agency breakout sessions.
- The Appreciative Inquiry approach followed the methodology that the Devon Children and Families Partnership had developed with Research into Practice as part of an earlier pilot.
- This case is still subject to a coronial process, however, there is no criminal investigation as cause of death was unexplained.
- All those involved shared findings and agreed key points of learning across the system.
- Each multi-agency group session was observed and facilitated by Nikki Soper, associate reviewer with Anthony Vaughan shadowing. During the feedback sessions from the groups, Quality Assurance Lead Kate Nightingale took notes for the post discussion reflections.