· Web viewThe Forensic Pathologist recorded the cause of death as severe malnourishment and...

Final Overview Report Case RK, March 2016.

SERIOUS CASE REVIEW

In respect of the death of Rebecca Kandare January 2014.

Report by: Birgitta Lundberg

Independent Overview Report Writer

March 2016

Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


CONTENTS:

1. INTRODUCTION

1.1 The circumstances leading to the Serious Case Review – brief summary1.2 The Serious Case Review process –brief summary 1.3 The Terms of Reference – brief summary

2. REBECCA AND THE FAMILY

2.1The community context and family circumstances 2.2 Key events and conclusions2.3 Information from the family

3. ANALYSIS

3.1 Analysis of services provided3.2 Analysis of themes 3.3 Conclusion and Findings

4. LEARNING

4.1 Lessons to be learnt 4.2 Implementation of learning

5. RECOMMENDATIONS

5.1 Recommendations by the Overview Report Writer5.2 Recommendations by the Wolverhampton Safeguarding Children Board.

6. APPENDICES

6.1 Appendix1- The full Terms of Reference6.2 Appendix 2- Serious Case Review Panel membership and agency participation6.3 Appendix 3 -Individual Management Reviews 6.4 Appendix 4- Bibliography



1. INTRODUCTION

1.1 The circumstances leading to the Serious Case Review – brief summary.

Rebecca was just over 8 months old at the time of her death in early January 2014. Her parents and some relatives recounted that she had had cold like symptoms for, varyingly, a few days or a few weeks. An aunt noticed that Rebecca was unresponsive early in the morning one day, when the family was in their church building, and an ambulance was called via the 999 service. Attempts were made at resuscitation in the church, on the way to and in the hospital but she was pronounced dead an hour later.

The SUDI (Sudden Unexpected Death in Infancy) protocol was followed by the health agencies, which included taking a full history, physical examination, blood, urine and CSF (cerebrospinal fluid) investigations, a skin biopsy and a skeletal survey.

A forensic post-mortem was conducted and the findings were that Rebecca was chronically malnourished with substantial muscle loss, pneumonia in both lungs and severe rickets. The Forensic Pathologist recorded the cause of death as severe malnourishment and bronchopneumonia, which can be attributable to failure to thrive. There was no evidence of underlying natural disease, either congenital or acquired, to explain the failure to thrive and it was noted that she had been born a healthy baby in April 2013.

It was confirmed during this review that no advice or treatment had been sought by the parents from any registered health professionals prior to this call for an emergency service. Rebecca had not been registered with any General Practitioner surgery at any point and was last seen by a Health Visitor in mid May 2013 when she was 22 days old.

Child Protection medical assessments were carried out the following day in respect of the two older siblings, both of whom were vitamin D deficient. Joint Child Protection enquiries (Section 47 Children Act 1989) and assessments were started to safeguard the welfare of the siblings. The children were made subject of Interim Care Orders in the middle of January 2014.

Following full Care proceedings the children have subsequently been safeguarded in a long term placement. As mother became pregnant whilst the criminal investigations were taking place, the unborn baby was made the subject of a Child Protection Plan and joined at birth to the Care proceedings for the siblings. The baby was removed at birth and placed with the siblings.



Both parents were arrested and interviewed on suspicion of causing their daughter’s death. They were later released with bail conditions under section 47 of the Police and Criminal Evidence Act 1984 including no unsupervised contact with the older children. As the parents answered bail early August 2014, they were re- interviewed separately and the conditional bail period was extended.

At this point the Crown Prosecution Service (CPS) reviewed the case and both parents were charged with murder. The cases were referred to the Crown Court and both parents were remanded to custody and bail applications were refused. The trial was rescheduled and after some delay the final trial took place in November 2015.

Both parents pleaded guilty to ‘manslaughter’ and were given prison sentences of respectively 9 years and 6 months (father) and 8 years (mother).

The church group, which practised in the building where the call had been made from, is known as one of the apostolic churches of Africa or the Gospel of God church. There are a number of groups of followers of its founder, Johane Masowe, who is seen as a prophet. There are some variations in beliefs between the different groups of followers. The family belonged to a local church, where the father of Rebecca was one of a number of Pastors. The parents had originally met through a similar church group nearby and then changed to this church group. This small group expects its followers to adhere to a range of beliefs about for example: dress codes for men and women, what types of work to do and limited contact with health agencies and medical treatments as they believe in the healing power of prayer. Any forms of treatment of ill health or preventative treatment such as immunisations are believed to be misleading as the underlying cause is believed to be spiritual, which can therefore only be addressed through prayer and other religious rituals. The church and its membership are described in the research available1as reluctant to trust state agencies or their representatives. The congregation is small in number and presents as being self-sufficient and separate from the local community.

1.2 The Serious Case Review process –brief summary.

Notification of a critical childcare incident was submitted to both the DFE and Ofsted on 17th January 2014 following information from the West Midlands Police to the Wolverhampton Safeguarding Children Board (WSCB) of the events.

A Serious Case Review Committee meeting took place and recommendations were made to the independent Chair of the WSCB, who agreed that the circumstances of the case met the criteria in Working Together to Safeguard Children 20132 and

1 see Appendix 4 Bibliography2 Relevant at the time ; now Working Together to Safeguard Children 2015 Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


regulation 5 of the Local Safeguarding Children Boards Regulations 2006 namely, that the WSCB should be:

5(1)(e)

Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.

(2) For the purposes of paragraph (1) (e) a serious case is one where:

(a)

abuse or neglect of a child is known or suspected; and

(b)

Either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

The Black Country Coroner’s office was informed by the Head of Safeguarding of the decision to undertake a Serious Case Review.

An independent Chair and an independent Overview Report Writer were commissioned to undertake the review supported by a Serious Case Review Panel, which consisted of senior managers from the relevant agencies. The managers and specialist advisors to the SCR Panel had not had previous involvement with any member of the family or direct operational responsibility for the case.

The membership of the SCR Panel and the Terms of Reference were agreed including the timeframe for the review. An additional Panel member with expertise in faith and cultural studies participated in the review in an advisory capacity. Individual Management Reviews (IMRs) and Information Reports were requested from the agencies involved and records were required to be secured.

The first SCR Panel meeting took place March 24 th 2014 and was followed by a ‘Briefing meeting’ for the authors undertaking the Individual Management reviews of the agencies identified as having had contact in their services with family members and Rebecca. All nil returns were noted. All IMRs and Information Reports were received within the agreed timescale.

For full details of the agencies involved and SCR Panel membership see Appendix 2. Serious Case Review Panel membership and agency participation.



A series of SCR Panel meetings, including a ‘Learning the lessons’ meeting took place between March 2014 and March 2015. The final draft Overview report was presented to the WSCB for approval in October 2015 as planned bearing in mind the timing of the criminal proceedings.

As the meetings with family members could only take place after the criminal process had been concluded, those meetings were arranged at the end of the trial in order to incorporate the learning from the family contributions.

1.3 The Terms of Reference – brief summary.

The Terms of Reference were agreed at the original scoping meeting and amended by the SCR Panel meeting in March 2014 to respond to updated information.

The review was asked to focus on the period of time from April 1st 2010 to February 28th 2014. To gain a historical understanding of both parent’s ‘parenting capacity’, IMR authors were requested to comment on any relevant/significant incidents for the period April 2002 to February 2014. In addition they were asked to take account of involvement with the older siblings and any safeguarding action to protect them.

Extracts from the Terms of Reference:

“The aims of the review were agreed as:

To review the background and circumstances leading to the death of Rebecca and ascertain whether there are lessons to be learnt for:

Individual agency working Effective inter-agency working Effective communication and information sharing Improving intra- and interagency working to better safeguard and

promote the welfare of children

Involvement of relevant family members would be sought as follows:

A letter to be sent to the parents advising them of the SCR process, inviting them to participate in and contribute to the review when appropriate and to advise that professionals will be accessing all family records, including health medical records.

Some historical information may be critical to this review in line with recent National Biennial SCR studies. However, if the IMR authors felt that there was pertinent information available prior to the scoping period for this review, then they should



include it in the chronology and IMR as it may shed some light on whether the circumstances leading to Rebecca’s death could have been predicted or prevented.”

For the detailed Terms of Reference see Appendix 1. The full Terms of Reference.

In addition to the generic terms of reference the SCR Panel agreed some specific questions for this review:

What guidance is available for staff when assessing a family where faith group beliefs may impact on safeguarding?

How are staff trained to identify risks that may be associated with faith group beliefs?

What guidance is available to staff if they find it difficult to gain access to a family and children?

IMR authors were asked to address why actions were taken, or not taken, by the practitioners or their supervisors.

The purpose of the review should be to focus on the lessons to be learnt and therefore the IMRs and the Overview report should address the following questions:

Are there lessons from this case for the way in which the organisations work to safeguard and promote the welfare of children? Is there good practice to highlight, as well as ways in which practice can be improved?

Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources?

Are there implications for current policy and practice?

2. REBECCA AND THE FAMILY

2.1 The community context and family circumstances.

Wolverhampton is an ethnically diverse city which has experienced a great deal of change over the past decade as the city’s population has increased by 6% to just under 250,000 people since 2001 alongside increased levels of overcrowding and deprivation.

The city is ranked in the Indices of Deprivation 2010 as the 20th most deprived nationally and is now one of the 10% most deprived local authorities in England. Over the last decade there has been a 10% decrease in White British residents and a corresponding increase in Black Asian Minority Ethnic (BAME) residents. In 2011,



BAME residents accounted for 36% of Wolverhampton’s population, a much higher proportion than had been initially anticipated.3

The majority of jobs in Wolverhampton have historically been in manufacturing, but recently service sector jobs have increased significantly. As a legacy of industrialisation, Wolverhampton is one of the most densely populated local authority areas in England, with a population density of 36 people per hectare based on the 2011 Census.

The two wards where the family lived and where the church was located are next to one another and quite central. There were local amenities and services within easy access including access to health agencies and the Children’s Centres.

The family: Information about the parents and the extended family was provided initially by some relatives and church members. Following the conversations with father and mother in the respective prisons, most of the original information has been confirmed.

Both parents were born in Zimbabwe and came to the United Kingdom to join other members of their family already settled there. Father arrived as a child in 1999, having been brought up by his grandparents, to join his parents, who were living in different places in the UK and Mother came as a young woman in 2002 to live with her sisters. Mother was intending to train as a nurse.

Father lived for a period of time in an area near London but then returned to live in the West Midlands and the Wolverhampton area in approximately 2008. Father has had a long term relationship with a white British woman and her child, which has continued throughout the period, covered by the review and has played a part in the family dynamics.

The parents met through attending one Gospel of God Apostolic church group in Wolverhampton, which was also attended by Mother’s sisters. Shortly afterwards they changed to another similar church group nearby, where they have remained members. The parents were married in accordance with this church group’s beliefs in October 2010.They were subsequently married in a civil ceremony in January 2013 as witnessed with a formal marriage certificate.

The two older siblings were born in December 2010 and January 2012 respectively.

A picture emerges of a family where the parents have steadily become more and more involved in the church life and activities; attending the church building and

3 (Department for Communities and Local Government, 2011)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


often staying there. The family often attended the church twice per day (6.00 a.m. and 6.00 p.m.). The children were required to attend unless they were extremely tired. The family stayed at the church most weekends. Father developed a role in the church as one of the ‘Pastors’ undertaking specific tasks for the church by leading sermons and getting involved in supporting members as well as undertaking trips to Zimbabwe to meet other members and Elders. He was ordained as a Pastor in Kenya.

The church advocates a strict dress code for men and women and regulates most aspects of daily life and regular prayers. There are many daily duties for the members of the church which lead its members to interact as a small group with limited contact with other people in their local community.

This local church group has firm views about not becoming involved with state institutions and modern medical treatment including immunisations and routine checks such as regular child health checks. They believe ‘that God determines whether a person lives or dies and that they will be saved by the Holy Spirit’.This has been illustrated by a number of reports including a Unicef research report in 2012 about the take up of health services for children and women in Zimbabwe4 and a Unicef report specifically about the Apostolic religion and maternal and child health services 20115.

The integrated chronology illustrates the changing behaviour of the family interactions with the Health visiting and GP services as the first born child initially underwent all checks and immunisations. When the second child was born the attendance began to falter and after the birth of Rebecca, there was no contact after a Health Visitor home visit in May 2013, 22 days after the birth.

There was one incident of domestic violence reported to the police by Mother in March 2012. Various sources6 have subsequently noted that Mother was taken to task by church members and the pastors for involving public agencies. Research about this particular group of the Gospel of God church notes that church members are held to account for their behaviour by public ‘naming and shaming’. 7 8 Both parents referred to this process or ritual as ‘cleansing’.

A significant part of the church’s belief about health agencies and medical treatments relates to child birth. The first child was born in hospital but the two subsequent births were reported several days after the event with the explanation that the church believes that mother and child must not be seen by any other person or leave the house for a period of seven days.

4 (Ha, et al., 2012)5 (UNICEF, 2011)6 From the child protection assessments7 (Reese, n.d.)8 See 2.3 Information from the familyRestricted. No information in this report may be used, copied or distributed without the prior permission of the author.


These unreported births at home are defined as ‘free birthing’ by the Nursing and Midwifery Council and, if attended by an unqualified person, it is an illegal act as set out in the Nursing and Midwifery Order 2001 Part 9 Article 44 and 45. The parents reported that Mother had been alone at the births but other information from the criminal process has indicated that a ‘prophetess’ from the church acting as midwife ‘Mbuya’ had been present. ‘Mbuya’ describes an older woman from the church, who has experience of marriage and raising children and is believed to have special spiritual powers and healing gifts.

Mother’s sisters, except one of them, are part of the same church. The paternal family are not. Some extended family members had regular contact with the children and shared in the care of them. The other women in the church group also shared in the daily care of the children including dressing and changing. The children were dressed in white layered clothing as prescribed by the church.

The health visiting and midwifery records demonstrate that Mother and Father gave different answers to practitioners about their work roles and studies variously reporting that Mother was a nurse and Father was a care worker for example. The family home described at home visits was recorded as clean and suitable for the children.

2.2 Key events and conclusions.

This section is not intended to reproduce the full integrated Chronology or Timeline, which were used in the review process by the SCR Panel and the ‘Learning event’ day. These tools enabled the Review Panel to cross reference the interactions by the different agencies and professionals in order to determine what actions and contacts there had been with the family, and Rebecca in particular, as well as between the professionals themselves.

As the information was collated patterns emerged about the births of the children, attendance for health checks (for Mother and the children) as well as the uptake of immunisations offered. The timing of changes in parental behaviour coincides in the Chronology with an increased participation by the parents, and Father especially, in church activities and an adherence to its beliefs. The Chronology also reflects a parallel drop off in contacts by Mother with agencies such as her GP after the domestic violence call out.

The following extracts from the integrated Chronology and Timeline are the Independent Overview Report writer’s view of significant information and events. In the light of the information gathered through the review process, specifically about how and why professional decisions were made and actions were taken and how



systems operated, it is clear that different responses by agencies at the time could have led to a different outcome for Rebecca and, therefore, her siblings.

2.2 1. The first late reported ‘free birthing’ at home.

In January 2012 sibling 2 was born at home. The birth was reported to Community midwifery services six days later by Father with the explanation that it had been unattended as Mother and baby could not be seen by anyone until seven days after the birth because of the family’s cultural beliefs. Father provided the new address as the family had moved.

At this point the Maternity matron contacted Children’s Social Care and enquired if the family was known to them. The Maternity matron also informed Children’s Social Care of the ‘free birth’ that had been reported in a brief telephone conversation by the Father. The conversation with Children’s Social Care did not lead to any further action as the family was not recorded as known to them. No risk was identified to the child by the Midwife, who had not yet visited. The contact by the Maternity matron with Children’s Social Care was prompted by the ‘Standards for Midwives’ which set out that following: “a ‘Free birthing’ or unplanned home birth’ - a check should be undertaken ‘for information’ with the local authority Children’s Social Care, to establish if there were any known concerns about the family.”

Simultaneously, the Head of Midwifery contacted the local police to discuss the report as according to regulations9 it is illegal for an unqualified person to act as a midwife. As there was no information available that anyone else had attended the birth, the police advice was that there was no cause to take any action. 10

During the review process it has been clarified that the Registrar’s Office had contacted the Midwifery unit to inform them that a man had tried to register a birth without a birth notification document and he had been advised to contact the Midwifery unit first as such a document was required.

It is a legal requirement to notify all births and deaths in the UK. The duty of notifying a birth to the appropriate medical officer within 36 hours rests with the father or any other person present at the birth, or within six hours of the birth. If a midwife is in attendance at a birth this notification is normally undertaken by the midwife.

9 (Nursing and Midwifery Council, 2009) Part 9 Articles 44 and 45. 10 Source : Health IMR Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


In order to formally register the child the father or mother must give information about the birth to the Registrar of Births and Deaths within 42 days of the birth.

A home visit was undertaken by the Midwife the following day and Mother stated that she had been alone during the birth, which had happened quickly. Sibling 2 was examined, weighed and consent to a vitamin K injection was given as well as a BCG (TB immunisation) appointment. The care of sibling 2 was transferred by the midwifery services to the health visiting services two days later and information about the ‘free birthing’ was provided in the transfer.

A home visit was undertaken by the Health Visitor and both sibling 1 and 2 were fully assessed in accordance with guidance at the time. The 8 to 9 month assessment of sibling 1, which had not yet taken place, was followed up as well. Sibling 1’s birth had been a hospital birth.

As a result of the information gathered and the observations made during the visit the Health Visitor concluded that sibling 2 would receive a ‘universal service’ level of input from health visiting services. The recording stated: ‘No previous history of involvement with social services and no safeguarding concerns identified today’ . The Health Visiting plan specified that: “New born hearing screening to be completed, consent obtained. Mother to attend child health clinics; engage with local children’s centres and to contact HV if required.”

This means that the main contacts would be at the local clinic for check-ups and with the GP surgery for checks and immunisations.

The administrative records demonstrated that the family were registered two weeks later with the Children’s Centre and the forms were signed by Mother. The records do not confirm if the two siblings were seen by any staff at the Children’s Centre. In early March 2012 a Family Support worker was recorded as allocated to the family, which was done routinely to trigger a ‘new birth visit’, but there was no evidence found that such a service had ever been provided. During the interviews in this review process it became evident that the siblings had attended the nursery a couple of times although no records could be found.

2.2.2. March 2012 and the Domestic violence report.

The Health visiting records noted that sibling 2 did not attend for the 6 week medical check-up with the GP in early March 2012.

By the middle of March 2012 the West Midlands Police received a report from Mother of an assault on her by Father. Uniformed police officers undertook a home



visit and found Mother holding the two children and Father present. The allegation was that Father had ‘grabbed Mother around the neck, punched and slapped her around the face’. The initial police log stated that Mother said that Father had ‘done this before but I haven’t called you’.11 Mother was distressed and both parents were spoken to separately. The parents suggested that they had been arguing about the woman from Father’s previous relationship with whom he was still spending considerable time.

Father was arrested on suspicion of common assault and removed to the police station. The police obtained a statement from Mother confirming the initial account and saying that she would not be willing to attend court in relation to the matter. The crime report stated that details were recorded for a WC 392 Domestic violence incidence form including a DASH12 risk assessment, which was graded as ‘standard risk’. Following the interview of Father the decision by the police was that there would be no further action as there were no independent witnesses, no CCTV, no medical evidence and one word against the other and the victim was unwilling to proceed to court. As a result Father was released.

As young children had been present, the incident was referred to a Barnardos Joint Screening meeting13, which took place a week later. These multi-agency meetings take place regularly between Health, Children’s Services and the Police with the purpose of sharing information between agencies and assessing domestic violence related reports. The different IMRs have slightly different information about that meeting and its outcome. See the Analysis in section 3.1 and 3.3 for further details.

The outcome was recorded by the police as ‘no need for any further action’.

The Health records noted that the incident was deemed to ‘score 2’,which was described as ‘a threshold scale of ‘2’.This takes into account ‘moderate to serious domestic abuse’ and was usually followed up by Family support services . However, there were ‘no actions to pursue’ for any health professionals in relation to this family noted in the health record.

The only reference to this domestic violence incident in the Children’s Services Information Report noted that a report had been logged by the police, who would not be taking any further action.

After this reported incident of domestic violence there was a gradual decrease in attendance by the Mother and children for immunisations and checks as well as GP attendance.

11 West Midlands Police IMR12 (Richards, 2009)13 Based on the Barnados Screening Tool national good practice model.Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


2.2.3. The second late reported ‘free birthing’ at home.

In late November 2012 Mother attended the GP surgery with the third pregnancy, which was estimated to be at 23 -24 weeks. A referral was made to an obstetrician due to the late booking but Mother was referred back to Midwifery led care as she was assessed as low risk. Mother did attend two ante-natal appointments at the hospital, although she did not book with the Community Midwife as advised.

The Review Panel confirmed that the two different GP surgeries, which the family had moved between, had different systems for women booking in with community midwifery services. The outcome was that after the birth of Rebecca the notification of the birth was sent by the Midwifery service to the wrong surgery, who did not act on it, and the fact that Rebecca was not formally registered with a GP was therefore missed.

In December 2012 sibling 2 missed the 9 month developmental check and in February 2013 sibling 1 missed the 2 year check. During the latter half of 2012 there had been a number of missed appointments for immunisations and check-ups which were followed up by phone calls and letters by the GP surgery and the Child Health monitoring system.

In January 2013 the parents underwent a civil marriage ceremony.

At the end of April 2013 a phone call was received by the maternity unit at the hospital to report the unattended birth of Rebecca at home. Two midwives visited the home on the same day as the birth was reported and it became clear that it had taken place seven days earlier.

When interviewed the midwives reported that ‘the house had been clean, tidy and warm. It was minimally furnished and no clutter was present. The Mother and siblings were all dressed in white. The siblings were playing well together and appeared happy and sociable’. Both midwives were made to feel welcome and the couple appeared open and honest when answering questions. Both midwives had discussed that there was ‘no fear’ in the house as everyone appeared happy. The birth had been very fast and no one else had been present with Mother when Rebecca was born, according to the parents. Mother told the midwives that she was a qualified children’s nurse. When asked why the family had not informed the midwifery unit before, Father said as part of their Zimbabwean culture mother and baby do not have contact with anyone for the first seven days. Mother added that she had a supportive family and many friends from the church.

New procedures had been implemented at the hospital since the ‘free birth’ of sibling 2 and a Datix incident form was therefore completed by the midwives on return to the hospital because of the event of Rebecca’s ‘free birthing.’Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


A Datix form is completed when there has been an issue out of the ordinary, or if procedures have not been followed, and it is deemed that there may be a risk. This incident then generates a Root Cause Analysis (RCA) review, which is investigated by a senior member of staff. All Datix reports are reviewed at a ‘Locality risk and effectiveness meeting’ and recommendations are then made.

In relation to Rebecca the ‘free birth’ was noted to be out of the ordinary but, as the parents had reported that no one else was present, it was judged to have been within the law. The conclusion was that post-natal care would therefore be provided as usual.

The previously mentioned notes from the Barnardos Joint Screening meeting about the domestic violence incident in March 2012 had been recorded in the Health visiting records in April 2012. However, this information was not present in the midwifery records. The RCA process did therefore not have access to all the information held about the mother and children in all the health records.

As the midwifery staff followed the new Datix process, there was no check this time to note new or additional information in relation to the child and the ‘ free birth’ with Children’s Social Care and the police. This was an opportunity where the domestic violence information might have come to light.

2.2.4. Patterns of missed appointments and take up of immunisations and checks.

By piecing together the information in the GP, Midwifery and Health visiting reports the number of appointments, contacts and reminders by the three different services and the record systems lead to a picture of a decreasing uptake by the parents of appointments for the children. The time period from the first birth of sibling 1 to Rebecca’s birth, during which the parents involvement with the church grew significantly, follows the same curve of decreasing engagement with the Health professionals from the information noted in the reports and the integrated chronology.

The table below taken from the report about the GP services to siblings 1 and 2 illustrates some of the issues:

DATE OUTCOME ACTION

14/01/11 S1 registration documents Registered at the GP practice



received

19/01/11 S1 attended for 6 week medical

No concerns noted

01/02/11 S1 attended for 1st immunisations

Immunisations given

01/03/11 S1 Attended for 2nd immunisations

Immunisations given

16/05/11 S1 Attended with eczema Emollients prescribed

25/05/11 S1 Attended with occipital lymph nodes

Reassured

17/01/12 S1 DNA for routine immunisations

No evidence of action taken

14/02/12 S1 DNA immunisations Not clear what action was taken

11/04/12 S1 Attended for routine immunisations

Immunisations given

11/02/12 S2 seen at surgery Noted to be a well-child , breast fed

27/03/12 S2 registration documentation received

Registered at GP surgery

27/03/12 S2 brought for 1st immunisations

1st Immunisations given

24/04/12 S2 DNA 2nd immunisations Patients spoken to and appointment rebooked

01/05/12 S2 attended for 2nd immunisations

2nd immunisations given

22/05/12 S2 DNA 3rd immunisations Noted to have an appointment for 29/05/12

29/05/12 S2 DNA 3rd immunisations Telephone message left with parents to rebook

19/06/12 S2 DNA 3rd immunisations saw dad who advised that mum was spoken to , message left on mums answer phone to re book



26/06/12 S2 DNA 3rd immunisations saw mum who rebooked for the following day

27/06/12 S2 DNA 3rd immunisations saw mum who stated was late at university and would make another appointment , mum did not make another appointment so admin were tasked to send an appointment

21/08/12 S2 DNA 3rd immunisations Tried to call mum ( no answer )

06/02/13 S2 DNA 3rd immunisations Letter sent to parents to book

There were a number of record systems for each child and individual adult involved across the Health agencies e.g. the individual GP records; the Midwifery records; the hand held maternity records; the hospital records; the health visiting records; the Child Health computer record system. Some of these record systems trigger alerts for failed appointments, DNA, but not when appointments were cancelled by the parents.

The explanations by the parents for missed appointments, which were recorded, do not state that the parents did not wish to have contact or services but give general reasons for missing the contact for example ‘being too busy’. The only context, in which the parents gave an explanation relating to their religious beliefs, was when notifying the local authorities of the two ‘free births’ at home.

As an example the following was noted:

‘Following two incidents of non-attendance for immunisation for sibling 2 in May 2012 and June 2012, a Health Visitor support worker visited the family home in July 2012. A letter had been sent to inform them of the visit and to clarify that the reason was to discuss non-attendance for immunisation. At the visit Mother stated that no letter had been received about that day’s visit. Mother also said that she wanted sibling 2 to have the vaccinations but had been busy as she was attending university.’ Mother’s statements were accepted without any further questions.

Following Rebecca’s birth there was a final midwifery visit in May 2013 when Mother was present with the children. The midwife reported to the review that she discussed the risks of ‘free birth’ with Mother and emphasised the higher risks with every birth encouraging Mother to deliver with a midwife next time. The midwife’s assessment was that Mother appeared to understand this. However, whether the fact that Mother understood the midwife’s point of view would have translated in to action with a new pregnancy is less clear, although it was assumed to be the case by the midwife. Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


The final visit by the Health visiting service in May 2013 reported that the parents were both present and consented to immunisation for Rebecca and the appropriate forms were completed and sent to the Child Health computer department. They also agreed to the BCG vaccine and a referral was sent to the Children’s Centre for this procedure. Parents consented for the new born screening to be completed and this had a normal result. However, they did not consent to the vitamin K injection, which was a change as they had previously consented with the older siblings. The vitamin K injection is specifically important when a baby is breastfed as Rebecca was.

During the review process interview the Child Health department reported that appointments for immunisation were sent to the home address for Rebecca on the following dates: 18/06/13, 16/07/13, 10/09/13 and the 8/10/13. It is understood that for all of these appointments an adult rang the department to cancel. It had not been recorded historically who called to cancel the appointments. The reviewer noted that the Child Health computer department is currently working on a spread sheet to record such cancellations and to record who rang to cancel. The current system does not inform the GP or Health Visitor if an appointment is cancelled – it only reports if the person fails to attend (DNA).

Between the different health systems and services involved, it was not discovered until after her death in January 2014, that Rebecca had not formally been registered with a GP.

2.2.5 Conclusions

The evidence of contacts with agencies by the parents, and therefore the children, increasingly demonstrated a falling off in the parents’ activity in attending appointments, in fact cancelling them rather than just missing them.

The information is somewhat contradictory about the willingness for uptake of medical treatment as at the times, when they were pursued by the Health professionals and visited at home, the parents did consent to a number of interventions. It was not recorded, or recollected at interview, that they had raised any religious objections except the cultural explanations given about the two ‘free births’.

Although the Time line correlated the falling off in health appointment attendance with the increased involvement with the church, the decreasing attendance also coincided with the time after the report of the domestic violence incident in March 2012. It has been reported by a number of relatives that Mother was taken to task by other pastors and members of the church for contacting the police thus involving outside public agencies. As a result of the interviews with Mother and Father the Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


church procedures, when a member has acted contrary to its beliefs, have been clarified. See 2.3 Family contributions.

The outcome for the three children was that the regular, universal child health services as set out in the national ‘Healthy Child Programme: Pregnancy and the First 5 Years of Life’ were not provided to them as time passed. The emphasis of the programme is on early intervention and help services to support families and children.

In addition to the decreasing uptake of the health visiting / child health services by the parents, the fact that the notification of Rebecca’s birth was passed to the wrong GP surgery, where it was not responded to correctly, led to a gap in GP services to her.

The fact that a routine allocation of a Family support worker was noted in the Children’s Centre records in March 2012 but no service was ever provided has been explained as an automatic allocation intended to trigger a ‘new birth visit’. There were no further records and the allocated person named in the records has no recollection of any involvement with the family at any time. The outcome may have been that the family appeared to have received a service, which was never delivered.

There were opportunities for the changes in parental attitudes and behaviour to be picked up by Health professionals at points in time as explored above. If a more questioning approach often described as ‘professional curiosity ‘had been taken, for example after the second ‘free birth’, the significance of the parents’ religious beliefs about the power of prayer, and the spiritual origin of any ill health, rather than interventions by medical services should have prompted a reassessment of the parents capacity to meet the children’s needs.

The opportunities for Family support services to be offered were missed by the follow up the Barnardos Joint Screening meeting. On the evidence of the records provided to this Review, the significance of the statement by Mother ‘that this was not the first incident but it had happened before’, was not picked up and considered in conjunction with the young age of the children as the information was not available to the meeting . In line with recommendations by the Munro Review14 for example the notion of Early Help services to prevent a need for child protection intervention applies in this case. Family support services at this point may have allowed the agencies to understand the Mother’s position better both in relation to the church beliefs and to the concerns about domestic violence and most of all to understand the impact on the children of the parents’ beliefs and behaviour.

14 (Munro, 2011)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


2.3 Information from the family.

Both parents agreed to meet with the Overview Report Writer in their respective prisons. The Serious Case Review process had been explained to them as was the purpose of the meetings. Mother’s Offender manager officer was present during the interview and could therefore offer follow up support. Father was seen on his own.

Both parents were encouraged to talk through how they had met and started their family and subsequently joined the Gospel of God church. Neither of the parents had been brought up within this church movement and both had come to it separately, although they had met through one of Mother’s sisters.

It emerged that they had been members of two different Apostolic church groups within the same geographical area in Wolverhampton. They had joined the church group referred to in this Review shortly after the birth of the oldest sibling.

The particular issues in this case relate to their congregation’s belief in the healing power of individual and collective prayer and for cases involving children the special healing attributed to the Mbuya, a member of the congregation with a special spiritual role and authority concerning children.

Father noted that with the two older siblings and other families’ children it had not been necessary to seek conventional medical treatment for childhood illnesses. The interventions of the Mbuya and prayer had been enough in his view. He expressed some surprise that this approach had not been sufficient for Rebecca.

Father and Mother were unable to explain who had made the phone calls cancelling the appointments for the immunisations.

Mother explained that any access to medical treatment had to be sanctioned by her husband and gave as an example a situation involving the oldest sibling. An accident had occurred and the sibling needed treatment after a fall causing bleeding to the head. Mother had to call Father so that he could make the decision that the child could be taken to the A and E for treatment. In that circumstance the treatment had to be reported to the Pastors and prayers as a ‘cleansing’ held subsequently as the beliefs of the church had been transgressed.

Both Mother and Father spoke of the process of ‘cleansing’. The church group is a small congregation with several pastors and sometimes one or more prophets. The men and women stand and sit separately in the main space and spend time in separate rooms, the women with the children. When a member is perceived to have Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


acted against the rules and beliefs of the group the person is placed on their knees in the middle between the two parts of the congregation and prayers are said over them.

For example, according to Mother after she had called the police in March 2012 she was ‘cleansed’ on many occasions and separated from the whole group for a time. Mother was told that she must be ‘obedient’ and set an example given that her husband was a Pastor. Mother did not think that she could in any way have contacted the police after this process began and stated that she had been forbidden to do so.

Mother and the children spent most of their time either in their house or in the church. Mother rarely went outside otherwise and when Father was away, for example in Kenya or Zimbabwe, Mother and the children were picked up for church by another male member of the congregation who had been assigned to them. Mother therefore had little contact with anyone outside the church group.

Father explained that the church allows a husband to have other relationships provided his wife is in agreement. It was his belief that Mother had agreed to this.

Mother did not feel that she had been asked for her views or agreement and this was an ongoing cause of tension between them. This had led to arguments which had sometimes escalated to violence. Mother felt that she was trapped in the situation and that her husband’s status as a pastor added to the pressure on her ‘ to be obedient’.

Learning point:

The main issues of learning for this review, and for professionals when assessing the influence of parental beliefs on their care of their children, concern understanding what questions to ask and how to interpret the information provided. There may be occasions when parents have to be challenged about the effect that their beliefs and the way they practice them will have on their children’s health. The professionals must reflect on the meaning of the beliefs and actions of the parents as carers of children.

The same exploration and challenge applies to questioning faith procedures or rituals where the actions of the group may affect the safety of an adult such as with domestic violence.



3. ANALYSIS

3.1 Analysis of services provided.

3.1.1 Health agencies:

The services in contact with the children first and foremost were the midwifery services, the health visiting services and the two GP surgeries. The children had been registered at the Children’s Centre, which included the health visiting team, and which was routinely notified of any ’new births’ in the area.

The health visiting service within Wolverhampton had experienced a period of change from 2012 including the relocation in April 2013 of health visitors from GP surgeries and Health Centres to work alongside their local authority partners in Children’s Centres. This coincided with the implementation of the Healthy Child Program15 which puts the emphasis on allocating resources to the most vulnerable children and their families.

The service provided by the health visiting team to the children had been assessed as a ‘universal service’ and there was therefore no named Health Visitor allocated to them. Any service to the family was provided by the team within a corporate caseload. The Healthy Child Programme categorises children as those, who have no extra needs or vulnerability as ‘universal service’, and those where concern is evident as ‘universal plus’. As a part of the universal service provision a 6-8 week check, immunisations, 8-9 month check and a 2 year check were offered.

There is no legal requirement for parents to comply with taking their children for checks or immunisations but the expectations of the national services and public health agencies are that it is ‘good parenting’ to promote the healthy development of any child and in the interest of public health for the community that immunisation programmes are delivered .

The records of the midwifery and health visiting services had been filled in well and especially the midwifery records were detailed about the children and home conditions. However, the family’s religion was not recorded in any of the health records although there were references to their ‘cultural belief’ about the births at

15 (Department of Health, 2011)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


home and not being in contact with anyone for seven days. Policies and procedures about respecting diversity, culture and religious beliefs were in place at the time in the services. The requirement for health visiting services to record religion and country of origin was introduced in December 2012.

Learning point:

The SCR Panel came to the conclusion based on all the IMR reports and interviews that the professionals had refrained from asking more searching questions of the parents about their religious beliefs. There was no evidence that any forms, that did have a field to ask and fill in the answer about religion, had been filled in. The reasons for professional hesitancy in asking questions may be varied but the learning point to consider is that unless clarification is sought by professionals, they cannot assess what the impact of a parents beliefs, of whatever origin, may be on their care of a child and their capacity to meet the child’s needs.

The record systems of the different parts of the health visiting, GP surgeries and midwifery services as well as the central Child Health department computerised system were organised separately and did not necessarily interact. This included information about non-attendance for immunisations and for checks. The ability of any one health professional to undertake an up to date review of a child would require that the professional was proactive and, in addition to exploring records, they would have to make direct contact with colleagues in order to gain a full picture of a child.

The communications between the different health professional groups based on information systems could therefore not be expected to be accurate or up to date. In addition as the family moved house a number of times records were transferred from one service point to another with some delays .So for example, the health visiting records were transferred to the second Children’s Centre in May 2013 and were therefore not available to the Health Visitor to access prior to the first visit to Rebecca after her birth. This was the only visit by the health visiting service. If the records had been available and used, the previous non-attendances might have raised concerns, which should have led to a reassessment so that all of the children’s outstanding checks could have been addressed.

The point was raised by one Health IMR that following the non-attendance of immunisations for sibling 2, the Health Visitor explained how the child health appointment system worked to Mother in terms of reports of DNA (did not attend appointment) and follow up. Subsequently, more than nine immunisation appointments were issued for Rebecca, which was many more than the DNA policy



required (two).This came about because each appointment was cancelled by the family but this did not register on the Child Health system as a DNA as it was a cancellation. There were no records of who cancelled the appointments or why. As a result this failure to attend the immunisations for Rebecca was not picked up by the health visiting team as they had not been notified through the usual system.

Similarly, it was not recognised by the health visiting team, the Children’s Centre registration process or the Child Health system that Rebecca was not registered with any GP.

Learning point:

Gaps in basic information such as GP registration must be followed up promptly and was part of the recommendations of the Victoria Climbié Inquiry:

Recommendation 12:

Front-line staff in each of the agencies, which regularly come into contact with families with children, must ensure that in each new contact, basic information about the child is recorded. This must include the child’s name, address, age, the name of the child’s primary carer, the child’s GP, and the name of the child’s school if the child is of school age. Gaps in this information should be passed on to the relevant authority in accordance with local arrangements. 16

The NHS Choice guidance states (last reviewed February 2015) that:

“Parents or guardians can register a baby at a practice by completing and presenting form FP58 (PDF, 34kb), which is issued at the same time as a birth certificate.”

It is not a statutory requirement to register a child with an NHS GP, or private health care provider, but the notification form above strongly advises parents to do so. The Review panel noted that health practitioners generally assume that children must be registered with a GP, although the records do not consistently demonstrate that practitioners have asked parents for the information or checked it themselves.

The system in place for disseminating the police WC392 domestic violence notification to the partner agencies was working in the health agencies, which can be verified by the records in the integrated chronology of receipt of the forms. The system in health agencies for receiving and noting the forms demonstrated that the

16 (Laming, 2003)


http://www.nhs.uk/NHSEngland/AboutNHSservices/Documents/Doctors/FP58.pdf


forms were scanned on to the Mother’s records in the GP surgery eleven days after the incident. There was no evidence in the records that Mother had discussed domestic violence with the GP subsequently.

The health visiting records noted the information about the domestic violence call out in mid-April in sibling 1’s records. No follow up action was taken in view of the ‘standard risk’ assessment outcome recorded from the Barnardos Joint Screening meeting.

3.1.2 Police response to the domestic violence report.

The report to the police of a domestic violence incident was made by Mother herself midmorning stating that “her husband was hitting her; he was still in the house and there were two children present”. The police responded straight away. Both parents were present and Mother was distressed and tearful holding the two siblings in her arms. The two uniformed police officers noted no visible signs of a disturbance. The parents were both spoken to separately and Father was arrested and removed from the home to the police station.

This was the first contact about the family and the children for the West Midlands police as there was no police record about the advice sought by the Midwife approximately six weeks earlier from them about the ‘free birth’. That conversation had been general about attendance at births by unregistered persons and was recorded in health records.17

As the crime report indicated the presence of a young child at the incident this case was referred to a regular Barnardos Joint Screening meeting, which took place within a week of the incident. The WC392 notification form18 circulated to partner agencies had recorded the presence and details of sibling 1 only. There was no written record on the form of sibling 2, who was only a few weeks old. This lack of detail would have inhibited the checking undertaken prior to these meetings by partner agencies and the Health representative in particular in view of the recent birth of sibling 2. The opportunity was therefore lost to assess the needs of and risk to both children accurately as the full information was not drawn together for the meeting.

The initial police log stated that Mother reported ‘that Father had done this before but that she had not called for help’. The formal statement that was taken by the uniformed officers made no mention of previous incidents. No evidence has been noted by this review to indicate that this Joint Screening meeting was made aware that Mother had commented that there had been past incidents.

17 See Health IMR18 This original form was made available to the Report writer and the Chair of the Review.Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


The police IMR noted that it was expected police practice at the time of the incident to provide the victim of domestic abuse with details of Domestic violence support agencies for future reference and support. The police records do not indicate if that was done in this case. Mother has no recollection of any support services such as Women’s Aid being mentioned.

The police response at the time of the incident was prompt and the forwarding of information for the Barnardos Joint Screening meeting in relation to the presence of young children followed the procedures in place at the time. There was some lack of focus on the children in view of their young ages and the officers accepted the reasons given by the parents for the incident e.g. the Father’s ongoing relationship with his previous partner. How far this information was conveyed to the Barnardos Joint Screening meeting has not been established as there were no minutes or notes taken at the meeting. The SCR Panel made considerable efforts to extract information about the outcome of the meeting.

Learning point:

The fact that the ongoing tensions in the relationship between the parents were not assessed in relation to the potential risk of further domestic violence incidents and the possible impact on the children was a missed opportunity. It should be noted that some of the Gospel of God groups believe in polygamy and if this was part of Father’s belief system the continued contact with, and financial support of, the other woman would have been likely to create tensions in the household in future.

It is important when considering the nature of risk in any case to assess the short term, medium or long term implications and whether the risks are static or dynamic to more accurately plan any support services.

3.1.3 The Barnardos Joint Screening meeting.

The history of the Barnardos Joint Screening meetings, based on a national good practice model developed by the charity Barnardos, goes back to 2010 in the West Midlands Police area, which covers seven local authorities including Wolverhampton. The police in partnership with the seven local authority Children’s Services promoted the introduction of the model. The model has subsequently evolved with different formats in those seven local authorities and with the involvement of local Community Safety Partnerships and Domestic Violence services.



The original proposals for the meetings were presented to the Wolverhampton Safeguarding Children Board and agreed as ‘good practice’ but were not formally adopted by the WSCB at that time (2010/11). The proposal was also put to the Safer Wolverhampton Partnership Board and subsequently both boards agreed to the development of the model. A regional review was undertaken by the West Midlands police in 2012 which updated the original protocol to try to standardise what had become a number of different approaches to joint screening across the region.

The meetings in Wolverhampton had not been chaired by an identified lead organisation during the period covered by this SCR. The cases, which were discussed, should be all domestic violence incidents reported to the police involving women with children and/or pregnant. The overall number of cases jointly screened was noted by the police at every meeting. Currently the police refer their reported incidents electronically to the partner agencies.

Representatives from the Police, Children’s Services and a Safeguarding Nurse jointly screen and assess cases with an Independent Domestic Violence Advisor (IDVA) from a domestic violence service in Wolverhampton. They share relevant information available in the respective agencies and each agency representative records case discussion outcomes and actions for their agencies.

However, the IMR reports from Health Visiting, Children’s Services and the Police have produced different perspectives in their records about this one meeting, to which the family had been referred.

As there was no clear record of who attended, the available information raised the query, if someone attended that specific meeting from Children’s Services at all. There was no record of such a meeting in their Information report. Their records noted the receipt of a written form WC 392 on March 23 rd 2012 prior to the meeting taking place. The record reads:

"Parents have had a verbal altercation whereby father proceeded to grab mother around the neck and slapped and punched her several times. Upon police arrival mother appeared to be distressed and crying. There were no signs of a disorder, mother stated that her husband had returned home after spending the night with his ex-girlfriend and this has caused an argument. Mother provided a statement and father was interviewed. Father has claimed that he was acting in self-defence. No further action by police.”

“Barnardos Scale 2 at this present time but if further incidents occur this will need to be reassessed. Letter of support also issued to mother."

It was not clear who had issued a standard letter, the Police or Children’s Services, or if a letter had actually been sent to Mother and received. It has not been possible



to locate a copy of a letter to Mother in any agency records. Mother has no recollection of receiving such a letter.

The police record noted that the meeting took place on March 26 th 2012. The incident took place on March19th. The police record ‘no further action’. The police IMR clearly stated that the attending officers had noted in their initial log that Mother was holding two young children and that she had said that there had been previous incidents, which she had not reported. The filled in WC 392 form, which has been provided to the Review, however, only mentioned sibling 1 and made no reference to previous incidents.

The records of the health representative, who attended the meeting, were placed in Mother’s GP records in March 2012 and in sibling 1’s health visiting case records in April 2012 and reads “392 police report of domestic abuse. Victim: female, grabbed around her neck, slapped and punched several times. Barnardos risk assessment: 2” “No report action required of health professional.”

The records, forms and notifications in relation to domestic violence incidents and the system for disseminating the information have been carefully reviewed within the SCR process. The conclusion was that significant information was lost in the transfer from one point to another in the system; that is, the whole pathway from the original call from Mother to the police to the outcome of the Barnardos Joint Screening meeting and the subsequent placing of the information on records. The incident took place on March 19th and the last agency to place the record on one child’s case records was in mid-April.

The effectiveness of the Joint Screening meeting was undermined by the presentation of the information from the original police call out and visit. The significant information about the presence of the two young children was partially missed as were the references to past unreported incidents. The form used by front line police officers did not prompt the person filling it in to ask any specific questions, such as ‘previous incidents?’ It was therefore up to the professional judgement of the attending officers what information was deemed significant and then recorded.

The way that the Joint Screening meetings have been conducted have left some representatives unclear about their role and therefore of the follow up from the meetings. The Health IMR, the Learning event and Panel discussion illustrated that there has been confusion about the process. There has not been an identified lead agency, which has raised the question of accountability for joint decision making. Each agency representative has responsibility for their participation as well as their records and their follow up actions and services.

Whilst information is shared in the meeting in a multi-agency format and the outcome of the meeting is agreed at the time, there is a lack of transparency about the decision making at the meeting as there is no collective record or minute of the



agreed actions to refer back to. Similarly there is no way to evaluate the process; the decisions and actions arising from it, as there is no joint record.

Learning points in relation to records:

Reports of domestic violence incidents must be recorded accurately by front line first response officers in order for the professionals further on in the information sharing process to be able to follow it up effectively with relevant checks as well as risk assessments. The full information must then be passed on through the whole pathway of information systems.

The people present at the time of the incident must be noted and in particular children. Any references to previous incidents, whether reported or unreported, must be recorded. The forms used, whether hard copy or electronically, must be designed to promote the key information requirements.

Learning points in relation to Joint Screening meetings:

The Barnardos Joint Screening meetings must enable the professionals and agencies to share and own the decisions made. There must be mechanisms in place to record the outcomes of discussions and what actions were agreed for whom.

The representatives attending the meetings must have a good understanding of the purpose of the process and their role in it. They must have a mandate to progress any decisions and actions agreed, whether the work is delegated or not.

The Barnardos Joint Screening meetings are a ‘good practice’ opportunity to bring together professionals with expertise of domestic violence and professionals with knowledge of child development and services for children. Sharing information and joint assessment of the impact domestic abuse may have on children in a household is intended to allow intervention with services at an early stage to prevent situations from escalating and to safeguard children. For such joint meetings to be effective the quality of the information available must be good and the standard of the discussion and decision making must be underpinned by a sound process.



A formal Review of the Joint Screening process in Wolverhampton; its operation, effectiveness, accountability and criteria, was started in July 2014 in response to this review. The Independent Review writer and the Review chair have received a Policy document setting out proposals for the new remit, structure, systems and governance for the Domestic Violence Barnardo’s Screening Tool (BST) multi-agency meeting screening process dated February 2016.

3.1.4 Subsequent Safeguarding services to the Siblings.

The response by Children’s Services jointly with health agencies and the police to safeguard the older siblings was prompt with full child protection medical assessments taking place the day following Rebecca’s death. Initially the siblings were left in the care of the parents while the cause and circumstances of death were investigated. The medical assessments of the siblings noted outstanding immunisations and vitamin D deficiency, otherwise they were judged to appear well cared for.

A Strategy meeting took place the day after and the children remained in the parental home with support from extended paternal family members. A follow up Strategy meeting a week later made the decision to commence Care proceedings in view of the information provided through the criminal investigation and the children were removed from their parents care. The older siblings were made subjects of Interim Care Orders eleven days after Rebecca’s death.

The agencies worked in partnership to safeguard the children and involved extended family members closely in the process. The Wolverhampton Safeguarding Children procedures were followed in the multi-agency response to Rebecca’s death.

3.2 Analysis of themes.

One of the key issues throughout this Review has been the question of balance between a set of beliefs held and practised by a religious group, which the parents of the child belonged to, and the needs of the child to be nurtured and safeguarded. It is the responsibility of the professionals and agencies providing services to children under the Children Act 1989 to promote the welfare of a child and as stated in Working Together to Safeguard Children 2015:

“Children are best protected when professionals are clear about what is required of them individually and how they need to work together.Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


This guidance aims to help professionals understand what they need to do, and what they can expect of one another, to safeguard children. It focuses on core legal requirements, making it clear what individuals and organisations should do to keep children safe. In doing so, it seeks to emphasise that effective safeguarding systems are those where:

the child’s needs are paramount, and the needs and wishes of each child, be they a baby or infant, or an older child, should be put first, so that every child receives the support they need before a problem escalates;

all professionals who come into contact with children and families are alert to their needs and any risks of harm that individual abusers, or potential abusers, may pose to children;

all professionals share appropriate information in a timely way and can discuss any concerns about an individual child with colleagues and local authority children’s social care;



high quality professionals are able to use their expert judgement to put the child’s needs at the heart of the safeguarding system so that the right solution can be found for each individual child;

all professionals contribute to whatever actions are needed to safeguard and promote a child’s welfare and take part in regularly reviewing the outcomes for the child against specific plans and outcomes;19

The themes, which have emerged from this Review, where improvements in practice or learning need to be addressed or systems need to be reviewed and updated, can be set out as follows:

The ability of practitioners and services to detect and assess parental beliefs which affect the basic care of a child.

Working with families reluctant to engage with agencies. Communications between agencies and professionals where there may be

concerns about a child. Information systems and recording practices.

19 Working Together to Safeguard Children 2015 Introduction para.12Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


3.2.1 The ability of practitioners and services to detect and assess parental beliefs that affect the basic care of a child.

The Wolverhampton Safeguarding Children procedures manual had a section at the time when Rebecca was born called ‘Race, ethnicity, religion and culture’ which was brief practice guidance, which stated the following:

4.1” Wolverhampton is a multi-cultural community. In order to make sensitive and informed professional judgements about a child's needs and parents' capacity to respond to those needs, it is important that professionals are sensitive to differing family patterns and lifestyles and to child rearing patterns that vary across different racial, ethnic and cultural groups. Professionals also need to be aware of the broad social factors that can discriminate against black and minority ethnic people.

4.2 The assessment process should always include consideration of the way religious beliefs and cultural traditions in different racial, ethnic and cultural groups influence their values, attitudes and behaviour and the way in which family and community life is structured and organised.

4.3 Professionals should guard against myths and stereotypes, both positive and negative, but anxiety about being accused of racist practice should not prevent the necessary action being taken to safeguard a child. Children from all cultures are subject to abuse and neglect and culture, race or religion cannot be a justification for acts of omission or commission that place a child at risk of significant harm.”

The specific church that the family belonged to is part of a wider group of the Apostolic faith community, which contains variation in beliefs about health care and medical interventions. The UNICEF report of 2011 in to the Apostolic religion 20

provides an insight in to the belief system and addresses constructive proposals about how to engage with the different church groups. Some of the report findings were as follows:

“The Apostolic members believe that the healing powers and spiritual gifts are endowed from God/Mweya, and used in promoting maternal and child health, facilitating child delivery and restoring health to the sick. Hence, the strong belief in faith healing , healing rituals, prayer and the power of God, all of which act as a barrier to the uptake of modern health care services and medicines.”

20 (UNICEF, 2011)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


“In addition, there is a widespread belief that reliance on modern medicines and healthcare services reflects the level of one’s faith, and it is generally associated with weak faith. Without affirming a moral judgement on the efficacy of faith healing or apostolic healing rituals, the refusal of some members to obtain medical treatment because of their adherence to religious practices can affect health negatively.”

In the case of Rebecca and the two older siblings, the two agencies which did have contact and provided services to them, missed opportunities to understand and assess the context in which the children lived. Although basic records asked about religion, none of the recording forms had noted this information. The SCR Panel concluded from the information in the IMR reports that practitioners do not routinely ask the question and record an answer.

The information about their church group was in fact provided by Mother and Father in relation to the two ‘free births’, which took place at home, but the significance of the parents’ beliefs for the care of the children was not understood by the professionals or explored further.

As a result the assessments, which were undertaken by the health professionals, did not address the issue, which significantly impacted on the health needs of the children. The only clue to the increasing withdrawal from accepting health services such as developmental checks and immunisations was the missed appointments and, after the birth of Rebecca, the cancellation of appointments. If a health professional had been able to have an overview of the lack of uptake of appointments it is likely that a reassessment of the children would have followed. The review process has confirmed that there are obstacles for health professionals to have access to detect a pattern of avoidance by a family as there is no easily available interface between the different recording and information systems.

Learning point:

Most Local Safeguarding Children Boards have chapters in their procedure manuals with reference to Faith groups and beliefs which affect children in various ways. The emphasis is generally on beliefs about ‘spirit possession’. No references have been found to date which specifically relate to a set of beliefs where the carers refuse medical and health services to children. The issue may be perceived as unusual or as an integral part of the assessment process, whenever a child and their parents are assessed. Assessments of parents’ capacity to meet their child’s needs should not be restricted to the roles of ‘mother ‘and ‘father’ only but should assess the adults as a ‘whole person’ with their beliefs and values included and in the context of their community ,in this case the church and any other significant relationships ,such as Father’s ex- partner .21

21 Featherstone, B., White, S. & Morris, K., 2014. Re-imagining Child Protection: Towards humane social work with families. Bristol: Policy Press.



Practice guidance and training for front line practitioners and their managers should incorporate the importance of analysing patterns of uptake of services and the impact on a child, if they are missing out because of the parents’ beliefs about health provision and medical interventions.

3.2.2 Working with families reluctant to engage with agencies.

There was at the time no specific practice guidance in the multi-agency WSCB Safeguarding Children procedures manual to support professionals and their supervisors/ managers to reflect on their practice with a family where there was a resistance to agency involvement. There was advice for practitioners as part of chapters about working with parents and children more generally such as chapter 9. ‘Working in Partnership with families’.

There was a policy in place in the health agencies, which was last updated in May 2013. The policy was called ‘Children’s did not attend/ no access policy’ and it was intended for all ‘child related services’. The policy stated that it: ‘provides a framework to support all practitioners to manage responses with regard to managing both non– attendance at health appointments and for families who are not locatable.’

The policy includes flowcharts of pathways to follow for various services and has a section about “Refusal of health visiting service/school nursing service by client” which sets out the actions to be taken to challenge and engage the family.

The particular circumstances of this family were not quite addressed as it was not an openly stated refusal of services except after the event in relation to the two ‘ free births’. The response by the Child Health system, health visiting and GP surgeries to the family cancelling appointments did not quite fit in with the systems in place and the gradual decrease in contact was therefore not discovered.

The term ‘disguised compliance’22 is often used in Serious Case Reviews to describe the family’s response to a professional contact: “. This was defused by apparent co-operation from the family. We have called this disguised compliance because its effect was to neutralise the professional’s authority and return the relationship to closure and the previous status quo.”23 22 (Reder, et al., 1993)23 (Reder, et al., 1993)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


In this case the family would agree to an immunisation or check-up but then subsequently cancel the appointment. In fact the system for monitoring appointments and DNA was explained in detail by the Health Visitor to Mother prior to the cancellations of appointments by someone in the family.

“Disguised or partial parental compliance also wrong-footed professionals. Apparent parental co-operation often prevented or delayed understanding of the severity of harm to the child”24.

Learning point:

If the professionals had recognised the pattern of withdrawal from health provisions they should have been taking action to reassess the needs of the children and Rebecca in particular. As the cause of death was noted to include ‘severe malnutrition’ regular health checks should have detected the signs and symptoms of malnutrition in a young infant and enabled the professionals to take action to improve Rebecca’s health and promote her welfare .

As the service provided was ‘universal’ there was not one allocated professional to track the pattern of service uptake but a review of the case records, which should include a chronology, prior to a contact (such as a home visit ) might have alerted the professionals to question the views of the parents more closely.

The Review Panel noted that in the contacts that the parents had had with health professionals, the parents had stated that they worked as health workers or Mother was studying to become a nurse. This information was never checked or verified by any professional. The information from the parents on interview was vague and referred to care work in the past with Father and Mother starting a course, which was not finished. Research studies of past SCRs have noted that professionals can be reluctant to question parents, who are perceived to be fellow professionals.

3.2.3 Communications between agencies and professionals where there may be concerns about a child.

There were opportunities at different points where the communication between professionals could have led to a better understanding of the home circumstances

24 (Brandon, et al., 2008)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


for the children, if the professionals had been more searching in their interactions with each other.

The conversations between the Midwifery matron and Children’s Services at the time of the first ‘free birth ‘of sibling 2 ,as noted in the records, consisted of a routine information request as to whether the family was known or not. The exchange noted that there were no known ‘safeguarding issues’ but this was at a time when the home birth visit had not yet taken place. It would have been good practice by the Midwifery service to review the circumstances after the visit and to have fed the outcome back to Children’s Services as the reported ’free birth’ was viewed as unusual.

Similarly, the Head of Midwifery checked the views of the police as attendance by an unqualified person at a birth might have been an offence. This was not recorded anywhere by the police and was dealt with purely as a legal question by both professionals rather than as a query involving the welfare of mother and child.

The second ‘free birth’, when Rebeca was born, was dealt with by the same midwifery professionals and this time there was no approach to update the queries with Children’s Services and the Police. The professionals proceeded to some extent on the basis of the previous information without updating it and referred to the new Datix process instead. This process was intended to enquire into an unusual event and it concluded that, as it was reported by the parents that there had not been an illegal arrangement with someone attending the birth, services would continue. This was a missed opportunity to reassess the circumstances of the children and the way they were being cared for.

The Review Panel viewed this as a significant lost opportunity to update information about the three young children, all in receipt of universal services, and to reassess their needs and Mother’s needs for Family support services. If there had been communication with the partner agencies at this time the recorded information from the Barnardos Joint Screening meeting should have come to light. The domestic violence report was not otherwise known to midwifery services.

The Barnardos Joint Screening meeting is intended to promote collaborative working where there are concerns about domestic violence and to provide sensitive services at an early stage for women and children. The key issue is therefore one of good communication in preparing for and participating in the process.

This Review has explored the process from the first contact to the outcome of the meeting and the provision of a service, if any. The format of the communication tools used by all agencies is primarily electronic forms and emails. In order to find clarifications and to discuss the meaning of the recorded information a direct contact by telephone would have to be made.



The communications within the agencies and between them has been unclear and confused, which led to important information being missed. The outcome of the joint screening meeting was a missed opportunity to engage with Mother and provide health services and Early Help support services to the children.

The information from the extended family anecdotally indicated that Mother was pressured in various ways by the church group to prevent her from contacting the police or other services again about domestic violence.25 The gradual disengagement with health professionals coincided with this time frame.

3.2.4 Information systems and recording practices.

The IMR reports account in their sections on methodology for the various record and information systems, which have been accessed within the agencies to review information about the family members held. This account demonstrates the number of different systems in place to record personal information about service users.

Within the West Midlands Police information may be recorded about a person on nine separate IT based systems in addition to the records, which form a part of a particular criminal investigation such as witness statements, interview records etcetera.

The health agency reports noted that the information systems included within the hospital trust were both medical records and nursing records, which can be accessed by the different disciplines. The health visiting and midwifery records are separate and mothers also have a handheld ‘red book’ for the child where checks and immunisations are noted. GP records are separate and access to each other’s record systems by GPs and health visitors vary in different GP surgeries. There was no requirement in place to link new-born babies to a GP practice.

The Children’s Centre recording systems were discovered through this review process to be in need of an urgent review as there were serious gaps in policy, procedures and practice. Action has already been taken to implement new systems and practice to ensure that Wolverhampton WSCB policies and procedures are adhered to.

Children’s Services have electronic record systems where information is kept on each individual separately but with links to significant others in place. Any enquiry of the system should be capable of checking any previous contact and referral such as the contact about the ‘free birthing’.

25 See section 2.3 Information from the familyRestricted. No information in this report may be used, copied or distributed without the prior permission of the author.


The importance of accurate record keeping and checks of the different systems has been noted in this case as information, which was presented to be shared, proved to be inaccurate and therefore misleading. If the Barnardos Joint Screening meeting had been aware of the presence of two young children and the mention of previous incidents the outcome of the meeting is likely to have been to provide a CAF (Common Assessment Framework) assessment and / or Family support services.

Entering personal service user records should not only be a routine task at the end of the day to account for workload management or performance monitoring, the records should reflect sound professional judgement about assessments, analysis and decisions. All records should be capable of understanding by the service user, if they exercise their right of access to their records.

Outcomes, actions and chronologies should be easy to view so that patterns of behaviour or signs and symptoms can be detected. Particularly where caseloads are shared as with the health visiting services all professionals should be able to use the information with confidence in working with a family. It should be routine practice to view information held prior to a home visit.

The front line police officers, who attend domestic violence incidents, must be aware of the importance of accurate recording and then how to transfer that information from logs to forms that go to the Barnardos Joint screening meetings. Their supervisors should ensure that records provided to the meetings have been checked for noting the presence of children and references to previous incidents.

3.3 Conclusion and Findings.

Having reviewed all the information available from agency internal reviews, including interviews with professionals, and following Panel discussions and enquiries it has been possible to reach conclusions about the lessons to be learnt and recommendations to be made in this case.

The review has concluded that there were specific opportunities that were missed, where a different response by professionals should have led to a reassessment of Rebecca’s needs, and those of the siblings. In the light of the post mortem findings of chronic malnourishment, pneumonia and severe rickets being the cause of Rebecca’s death it was agreed that, if there had been contacts with health visiting and GP services, the signs and symptoms in Rebecca would have been noticed. This would have led to appropriate services being provided by all agencies, which would have prevented Rebecca’s death. In reality Rebecca had not been seen by any health professional since she was 22 days old.

Based on the available information a pattern emerged which related to two separate but interlinked developments. These were the increased involvement by the parents Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


in the Gospel of God church group, which has set beliefs about interactions and uptake of health services, and the outcome for Mother of her report of domestic violence to the police and the response to it by the church and Father in March 2012. These developments led to a withdrawal from health agencies in particular as well as the police in relation to the domestic violence.

As the agencies had little understanding or knowledge about the church groups’ belief system and professionals were not enquiring about the parents’ views about health services, it would not have been possible to predict Rebecca’s death. There was no known background history of either parent to raise any concerns about their care of their children otherwise.

The research reports by UNICEF from 2010/11bring out the higher rates of infant deaths related to the beliefs of some Apostolic churches ,who are opposed to the uptake of modern health service provision and strictly advocate the power of prayer and healing instead. This information would not have been easily accessible to the professionals involved with the family at the time but as a part of learning from Rebecca’s tragic death professionals should in the future be able to engage with families with such beliefs more effectively to prevent similar outcomes to other children.

4. LEARNING

4.1 Lessons to be learnt.

Several lessons to be learnt have emerged from this Serious Case Review which must be followed up to ensure that practice improves and where practice has already been addressed as a result, mechanisms must be in place to embed and maintain the improvements .

The sections above have sought to draw out ‘Learning points’ to highlight significant episodes, where the outcome for the children might have been different, if the professionals had acted with a more focussed approach on the effect on the children of the care of those around them. If the professionals had understood the context of the family and church environment, they should have recognised concerns about the quality of the care provided by the significant adults.

In brief the following learning points were noted, where improvements in practice would have made a difference:

In the course of assessments professionals should not refrain from asking parents and carers about their faith or beliefs as those form a part of the world in which they interact with the child and their community. The interplay of beliefs of whatever origin and how parents respond to and care for their children is inevitably complex but an adult must be viewed by professionals



not only in their parental role but as a whole person to achieve a meaningful assessment of their care of their children.26

The need for professionals to update or undertake reassessments of a child’s circumstances in the light of new events or information should be part of regular good practice and reflection in supervision, so for example the second free birth should have prompted an update of the previous assessment rather than have relied on the past information and the Datix process.

When undertaking a home visit especially where caseloads are shared, it is good practice to check available information prior to the visit.

The recording practices in agencies should address accurate and significant information taking such as the front line police officers attending domestic violence call outs. If the original information noted by a professional is not accurate or relevant the assessments, decisions and actions taken by other professionals, such as at the Barnardos Joint screening meetings, may miss significant information.

In brief the following points were noted where specific services should have functioned more effectively and where improvements could be made:

The recording and multi-agency information sharing process to assess domestic violence call outs involving women with children and / or pregnant must be improved. As the process is centred on the Barnardos Joint screening meeting, the review of this meeting must address the way it is organised and how it functions.

The accessibility to information systems and the best way to ensure that they work for professionals to enable them to share information accurately with each other must be reviewed and improved in all agencies. This is particularly relevant for GPs and Health Visitors to be able to work collaboratively since the relocation of practitioners to Children’s Centres.

Professionals should have confidence that information systems can detect and report patterns of uptake of services accurately, so that, if there are signs of a child missing out on basic universal child health provision, the matter is followed up and reassessed.

4.2 Implementation of learning.

The learning from this Review is not limited to the agencies that were directly involved but extends to all agencies involved with families when there are concerns about the consequences of parental beliefs on the care of the children. The learning must be disseminated to all the agencies to reinforce with practitioners that they

26 (Featherstone, et al., 2014)Restricted. No information in this report may be used, copied or distributed without the prior permission of the author.


must exercise their professional judgement and not be vary of asking searching questions in the course of their work.

Each agency is expected to provide feedback to their own agency and the IMR authors as well as to the professionals, who were involved in the review process, at the time of publication of the report.

Post publication there will be ‘SCR Learning the lessons’ events provided by the WSCB within a month of publication supported by ‘Lessons Learnt’ Briefings across the partnership.

The learning will be incorporated in to the rolling WSCB training programme.

The progress of the implementation of the recommendations below will be monitored by the Wolverhampton Safeguarding Children Board Business unit, who will report regularly to the WSCB. Each agency involved will be required to provide evidence to the WSCB of the progress made in accordance with the agreed Action Plan. See the Action Plan on the WSCB website

5. RECOMMENDATIONS

5.1 Recommendations by the Overview Report Writer.

This Review was undertaken in the main between March 2014 and March 2015. The timescale of the criminal process impacted on progress as family members could not be included in the process until after the trial in November 2015. The agencies were all expected to address any learning as it emerged during the review process to avoid any undue delay.

All Individual Management Review report recommendations are set out in the Action Plan, which can be accessed on the WBSC website, and address the Terms of Reference and findings. The recommendations in the IMRs were judged by the Serious Case Review Panel to have addressed the findings comprehensively with the exception of the West Midlands Police IMR, which had not made any recommendations; this has been addressed in the Overview Report Writer’s recommendations below.

The SCR Panel noted that work in the agencies involved has progressed during the course of the Review in response to those recommendations. For example:

A review has commenced of the Child Health system to enable it to report cancellations;



A review has commenced of the process to respond to domestic violence reports and the Barnardos Joint Screening meetings.

An urgent review has also been acted on in relation to the recording policies, procedures and practice in the Children’s Centre.

The following are the specific recommendations by the Overview Report Writer arising from the key themes and main learning points, which have been drawn up in order to ensure that all relevant interagency learning from the Review is addressed:

Learning point 1.

There is a need to improve knowledge and understanding by professionals about the potentially damaging effect on children in relation to the uptake of basic child health services, where parents and carers believe in other forms of healing such as prayers or rituals, which are used to address the origins of the ill health. The beliefs may lead to adverse effects on a child’s health and development by withholding treatment.

Where there are faith groups in the local community with views, which are resistant to the use of public health services, medicines and treatments, a dialogue should take place to develop mechanisms for working together constructively to ensure that the children affected are safeguarded and their health and wellbeing is promoted.

‘The National Acton Plan to tackle child abuse linked to faith or belief 2012’ includes practical suggestions as do the UNICEF reports noted.

Recommendation 1.

The Wolverhampton Safeguarding Children Board and its partner agencies should undertake a review of their current involvement with local Faith groups. They should set up a Working Group to map local faith groups in the city and develop a strategy to promote constructive involvement with local communities and Faith groups where there are beliefs which may inhibit involvement with child health services to the detriment of children.

Learning point 2.

A number of learning points about good practice in assessments, in sharing information and in recording personal information have been highlighted in this Review.



Recommendation 2.1

Interagency and single agency training should routinely incorporate the lessons from this Review in courses relating to Assessments, Domestic Violence, ‘Working with faith groups and cultural beliefs which affect children’ and record keeping.

Recommendation 2.2.

In order to underpin the learning and to support professionals with good practice guidance the multi-agency Wolverhampton Safeguarding Children Board procedures manual should be reviewed in relation to:

Working with parents and carers where there may be issues of child abuse or maltreatment in relation to specific beliefs or faith groups.

Working with parents and carers who are reluctant to engage with services.

Learning point 3.

The Review has demonstrated that the record keeping practice of the West Midlands Police and, in particular, the WC 392 form in place for front line police officers when responding to domestic violence call outs is a crucial document in providing information. The information recorded on this form is then relied on in the system set up to assess needs of and risks to adult victims and children.

Recommendation 3.1

The Wolverhampton Safeguarding Children Board should request that the West Midlands Police review their current recording training for front line officers and their supervisors to emphasise the need for accuracy and what information is significant in relation to domestic violence.

Recommendation 3.2

The Wolverhampton Safeguarding Children Board should request that the West Midlands Police should review the design and layout of their current WC 392 notification form and update the key information required.



Learning point 4.

The Barnardos Joint Screening meetings should provide a good interagency system to share information and assess the needs and potential risks to children and adult victims relating to domestic violence. This Review has revealed that there is confusion among the participating professionals about the remit, accountability and format of the system and meetings.

Recommendation 4.

The Wolverhampton Safeguarding Children Board has started a review process in response to these findings and the lessons from this Review should be incorporated in that work. There must be clarity about the roles and responsibilities of agency representatives and a joint ownership of actions agreed.

Learning point 5.

There is a proliferation of Information systems in the agencies, which have participated in this Review. The ability of professionals to access up to date information about children of all ages is hampered by the range of systems in health and the police in particular. If families move between areas and services, it can add to the confusion. Professionals need to be alert to the fact that they must query information held and undertake up to date checks in some cases directly with other professionals particularly where some time has passed as there may be new information held for example in relation to domestic violence.

Recommendation 5.

The key partner agencies in this Review; all the health agencies including the Children’s Centres and the Child Health department ,the Police and Children’s Services must review and improve their information systems in relation to:

The information received about domestic violence call outs and the outcomes from the Barnardos Joint Screening meetings –to specify:

o who receives notifications; o where information is placed/ filed,o how information is linked to relevant others o who can access relevant information easily



Commissioners of Maternity Services, Primary care services, Child Health Information Systems and Health visiting must implement systems, processes and protocols that would identify and trigger responsive actions when a child;

o Is not registered with a GP ( or equivalent provider) after birth;o Does not attend appointments on a consecutive number of times( to be

agreed locally and reported to the WSCB) ;o Does not attend appointments but a reason i.e. a cancellation is given

on a consecutive number of times( to be agreed locally and reported to the WSCB) ;

o Or any combination of the above.

Professionals must check that children are registered with an NHS General Practitioner (or the equivalent private provider) after birth and current record systems must be reviewed and updated to implement this requirement.

Birgitta Lundberg, Independent Overview Report Writer.



6. APPENDICES

Appendix 1.

6.1 The full Terms of Reference.

6.1.1

Aims- to review the background and circumstances leading to the death of Child RK and ascertain whether there are lessons to be learnt for:

Individual agencies working Effective inter-agency working Effective communication and information sharing Improve intra- and interagency working to better safeguard and promote

the welfare of children

6.1.2

Involvement of relevant family members:

A letter to be sent to the parents advising them of the SCR process, inviting them to participate in the review and to advise that professionals will be accessing all family records, including health medical records.

6.1.3

Some historical information may be critical to this review in line with recent National Biennial SCR studies. However, if agencies through IMR authors feel there is pertinent information available prior to the scoping period for this review, then they should include this in the chronology and IMR. It is hoped this will shed some light on whether the circumstances leading to Child RK’s death could have been predicted or prevented.

6.1.4

All IMR’s and the Overview Report should address the following:

1. Were practitioners aware of and sensitive to the needs of the child in their work, and knowledgeable both about potential indicators of abuse or



neglect, and about what to do if they had any concerns about a child’s welfare?

2. When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?

3. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?

4. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?

5. Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquiries made, in the light of assessments?

6. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services?

7. Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?

8. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?

9. Were senior managers or other organisations and professionals involved at points in the case where they should have been?

10. Was the work in this case consistent with each organisation’s and the WSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?

11. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?

12. Was there sufficient management accountability for decision making?

6.1.5

What do we learn from this case?

Are there lessons from this case for the way in which this organisation works to safeguard and promote the welfare of children? Is there good practice to highlight, as well as ways in which practice can be improved?

Are there implications for ways of working; training (single and inter-agency); management and supervision; working in partnership with other organisations; resources?

Are there implications for current policy and practice?



6.1.6

In addition to the above generic terms of reference, the Serious Case Review Panel agreed that agencies should address the following issues which are specific to this case:

What guidance is available for staff when assessing a family where faith group beliefs may impact on safeguarding?

How are staff trained to identify risks that may be associated with faith groups?

What guidance is available to staff if they find it difficult to gain access to a family and children?

IMR’s should address why actions were taken, or not taken by the practitioner or their supervisor.

Appendix 2.

6.2 Serious Case Review Panel membership and agency participation.

6.2.1

The SCR Panel:

The SCR panel included representatives from:

Wolverhampton CCG Royal Wolverhampton NHS Trust Early Years Community Safety Partnerships West Midlands Police Children, Young People and Families (Social Care) Head of Service, Safeguarding Children & Adults Co-ordinator of Youth Organisations Wolverhampton Cultural/Faith expert invited by the SCRP



The Independent Review Writer attended the Panel meetings with the exception of one meeting.

6.2.2

IMR authors:

The following agencies completed Independent Management Reviews:

Royal Wolverhampton Hospital Trust Wolverhampton CCG (Primary Care GP Services and HOR) Children’s Early Help Services West Midlands Police West Midlands Ambulance Service (Brief report and Chronology)

Wolverhampton CC Children’s Social Care was requested to provide an Information Report and chronology as no previous contact with the family members had been recorded.

Wolverhampton Domestic Violence Forum and Staffordshire and West Midlands Probation Services confirmed that they had not had any contact with this case.

6.2.3

Agency participation in the SCR review process.

The SCR Panel met on five occasions and one IMR Author briefing session took place at the beginning of the review. This Briefing session at an early stage in the process served to support the reviewers, who were undertaking the individual agency reviews.

The Independent Chair led a Learning event day which was attended by the IMR authors, some key front line practitioners and Panel members and the Report Writer. Useful discussion about services and learning points took place and added to the understanding of the participants of the circumstances of the case.

The Panel sessions attendance was regular although the Children’s Social Care Services and West Midlands Police did not attend all meetings. In the case of the police, pressures of workload and organisational change were noted.

There was some initial confusion about the representation from Children’s Social Care Services which appeared to relate to the fact that there had been no recorded direct service involvement with the family. The SCR Subgroup’s original request to



Children’s Social Care Services had been for an Information Report, which was provided. This set out the family background and decisions and actions after Rebecca’s death.

With hindsight Children’s Social Care Services should have provided an IMR as they are a part of the multi-agency network and as such have responsibilities in relation to the Barnardos Joint Screening meetings and the processes around those meetings. A more robust examination of this process in relation to this case should have been provided by them.

As this information and analysis was not provided the SCR Panel, the Chair and the Report Writer spent some time following up this information in correspondence with Children’s Social Care Services representatives in order to try to establish the history and remit of these multi-agency meetings and processes. As Children’s Social Care Services are the lead agency in child protection services the fact that there had not been any recorded contact with the family or children might be a learning point in itself and therefore merited a more thorough review than that provided in an Information Report.

It has emerged from the review that there is confusion about roles and responsibilities in relation to the Joint Screening meetings and in some respects the low key participation by Children’s Social Care Services in the Panel and the Review reflected some of that confusion.

Appendix 3.

6.3 Individual Management Reviews

The IMR reports were produced by all agencies within the timescales requested and followed the format and guidance, which had been provided by the WSCB. The integrated chronology was compiled at an early stage in the review process which was helpful to the reviewers and aided the review process.

The administration of the review process and the documentation was efficiently carried out by the WSCB Business unit and the CDOP Coordinator, who supported the Panel meetings with taking minutes and other tasks.

The IMRs provided for the different health agencies; GP services, Health visiting services, Midwifery services and hospital services including Child Health monitoring services were all thorough with relevant learning points and recommendations for improvements and action. Some of the issues raised during the review have been actioned prior to its conclusion as the IMR process had identified gaps or areas for change.



The Panel had considerable discussions about how information systems operate in health agencies and who has access to which systems. The particular need to establish a system for new born children to be registered with a GP service was agreed. The review process has led to recommendations and an Action plan, which will address the areas identified. The IMRs included mechanisms to monitor and audit the implementation of the recommendations to ensure that they become embedded in practice.

The West Midlands Police IMR was informative about the risk assessment model DASH and the levels of domestic violence referrals. The IMR also reflected on the impact on services of organisational change.

The IMR analysed the response by the front line staff to the domestic violence call out in some detail and noted that some actions had not been followed through and some recording had not been accurate. However, the IMR author did not draw out any learning points from the issues about accurate observation and recording all through the police systems including the Barnardos Joint screening meetings.

The IMR author had not made any recommendations in the single agency review. As the full SCR process has resulted in a number of learning points around the agency responses to domestic violence incident reports and the Joint screening process, it was a gap in the IMR that lessons had not been translated in to recommendations. This issue was raised in the Panel Learning event with police representatives and it was agreed that the Overview report would reflect this learning.

At the meeting with the WSCB in October 2015 the West Midlands Police representative raised some queries in relation to the Overview report which led to a brief written submission. The submission has been responded to in the final Overview report and some minor corrections of fact made. However, the overall original conclusions and findings were not amended as these were based on the documentation provided to the review and the Panels discussions including a detailed letter requesting additional information from the Police IMR reviewer. The police representative on the Panel had also participated in reviewing the records and information.

The initial IMR report from the Children’s Centre had struggled to access any records at all and therefore to proceed with a review. The IMR process was revised and assistance to undertake the review was provided by the Early Years’ service. An urgent action plan was put in place to address the lack of any record/ recording systems, which should have been in place.

A significant change in staffing and management of the Children’s Centre has been taking place during the period of this Serious Case Review and an Action Plan is now in place, which reflects the significant learning from this Review. The learning addresses both the training for staff and the use of recording systems and the role and involvement of the Early Help locality boards particularly in developing a “New birth visit” policy.



All the recommendations made in the IMRs will be monitored by the agencies with regular progress being reported back to the WSCB to ensure that the learning is progressed and embedded.

Appendix 4.

6.4 Bibliography

Brandon, M. et al., 2008. Analysing child deaths and serious injury through abuse ad neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005, s.l.: DCSF Publications DCSF-RR023.

Cleaver, H., Unell, I. & Aldgate, J., 2011. Children's Needs - Parenting Capacity. 2nd ed. s.l.:HMSO.

Department for Communities and Local Government, 2011. English Indices of Deprivation 2010. [Online] Available at: http://www.gov.uk/government/statistics/english-indices-of-deprivation-2010

Department of Health, 2011. Health Visitor Implementation Plan 2011-15 - A Call to Action, s.l.: Department of Health.

Featherstone, B., White, S. & Morris, K., 2014. Re-imagining Child Protection: Towards humane social work with families. Bristol: Policy Press.

Ha, W., Salama, P., Gwavuya, S. & Kanjala, C., 2012. Equity and Meternal and Child Health - Is Religion the Forgotten Variable? Evidence from Zimbabwe, s.l.: UNICEF.

HM Government, 2013. Working Together to Safeguard Children. [Online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281368/Working_together_to_safeguard_children.pdf

Kingston University Institute for Child Centred Interprofessional Practice, 2014. A Study to Investigate the Barriers to Learning from Serious Case Reviews and Identify ways of Overcoming these Barriers, s.l.: Kingston University.

Laming, L., 2003. The Victoria Climbié Inquiry Report, s.l.: HMSO.

Laming, L., 2009. The Protection of Children in England: A Progress Report, London: HMSO.

Munro, E., 2011. The Munro Review of Child Protection: Final Report - A child-centred system, London: HMSO.



National Panel of Independent Experts on Serious Case Reviews, 2014. First Annual Report, s.l.: HMSO DFE-00531-2014.

Nursing and Midwifery Council, 2009. The Nursing and Midwifery Order 2001 (SI 2002/253) Consolidated Text. [Online] Available at: http://www.nmc-uk.org/Documents/Legislation/Nursing-and-Midwifery-Order-2001-Consolidated-text-effective-from-20090514.pdf

Nursing and Midwifery Council, 2012. Midwives Rules and Standards 2012, s.l.: HMSO.

Reder, P., Duncan, S. & Gray, M., 1993. Beyond Blame: Child Abuse Tragedies Revisted. 1st ed. London: Routledge.

Reese, R., 2008. Johane Masowe, Gospel of God Church, Zimbabwe. [Online] Available at: http://www.dacb.org/stories/zimbabwe/johane_masowe.html

Reese, R., n.d. Lessons in Mission from an African Initiated Church: A Case Study of the Zimbabwean VaPostori of Johane Masowe. [Online].

Richards, L., 2009. Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH,2009) Risk Identification and Assessment and Management Model. [Online] Available at: http://www.dashriskchecklist.co.uk

Simon, A., Hauari, H., Hollingworth, K. & Vorhaus, J., 2012. A Rapid Literature Review of Evidence on Child Abuse Linked to Faith or Belief, s.l.: Childhood Wellbeing Research Centre.

The National Working Group on Child Abuse Linked to Faith or Belief, 2012. National Action Plan to Tackle Child Abuse Linked to Faith or Belief, s.l.: s.n.

The Royal Wolverhampton Hospitals NHS Trust, 2014. Delivery Suite Guide to Practice: Unplanned Homebirth, s.l.: s.n.

UNICEF, 2011. Apostolic Religion, Health and Utilization of Maternal and Child Health Services in Zimbabwe, s.l.: UNICEF.

WSCB, 2014. Wolverhampton Safeguarding Children Procedures. [Online].

WSCB, 2014. WSCB Safeguarding Children Procedures. [Online].


· Web viewThe Forensic Pathologist recorded the cause of death as severe malnourishment and...

Documents

Transcript of · Web viewThe Forensic Pathologist recorded the cause of death as severe malnourishment and...