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KIRKLEES SAFEGUARDING CHILDREN BOARD

SERIOUS CASE REVIEW RELATING TO A CHILD

WHO DIED AGED 2 YEARS 11 MONTHS

OVERVIEW REPORT BY DR CAROLE SMITH – INDEPENDENT AUTHOR

JULY 2011

NOTE: It should be noted that this overview report has been written for Kirklees Safeguarding Children Board to fulfil the purpose of a Serious Case Review. However, the Serious Case Review Overview Panel and the independent author also had to consider the implications of including detailed information about the child and family in this report as the Government requires that it should be published. Therefore, certain details which may indicate the identity of the child and other family members or otherwise intrude unnecessarily upon their privacy have been omitted.

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Contents of Overview Report

Paragraphs Contents

1.0 Introduction 2.0 Genogram recording family composition and relationships 3.0 Reasons for the Serious Case Review 4.0 The Serious Case Review process 5.0 Terms of reference for the Serious Case Review 6.0 Methodology for conducting the Serious Case Review 7.0 Implementing multi-agency action plans 8.0 Ethnic, cultural and equalities issues that may be relevant to

professional practice and conduct of the Serious Case Review 9.0 Social and Emotional history of parents/carers 10.0 The policy and practice context 11.0 The child at the centre of the Serious Case Review 12.0 Description and analysis of Individual Management Reviews 13.0 Descriptive account of Year 1: July 2007 to end of December

2007 14.0 Analysis of Year 1: July 2007 to end of December 2007 15.0 Descriptive account of Year 2: January 2008 to end of

December 2008 16.0 Analysis of Year 2: January 2008 to end of December 2008 17.0 Descriptive account of Year 3: January 2009 to end of

December 2009 18.0 Analysis of Year 3: January 2009 to end of December 2009 19.0 Descriptive account of Year 4: January 2010 to the child’s death

on 17/11/10 20.0 Analysis of Year 4: January 2010 to the child’s death on

17/11/10 21.0 Overall analysis and conclusions: major issues and learning

arising from this Serious Case Review 22.0 Evaluation of the Serious Case Review process 23.0 Other Serious Case Reviews completed by Kirklees

Safeguarding Children Board 24.0 Complete list of recommendations 25.0 Conclusion 26.0 Detailed record of the mother’s attendance at appointments and

availability for pre-arranged home visits

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Key to Abbreviations

AT (1 and 2) Advisory Teacher for the Hearing Impaired CAF Common Assessment Framework CCIO Child Care Inclusion Officer CHFT Calderdale and Huddersfield NHS Foundation Trust CLW Community Link Worker, Sure Start Children’s Centre CRH Calderdale Royal Hospital FSW Family Support Worker, Sure Start Children’s Centre HV (1, 2 and 3) Health Visitor IMR Individual Management Review KAHT Kirklees Accessible Homes Team KCHS Kirklees Community Healthcare Services KISS Kirklees Information Sharing Service KSCB Kirklees Safeguarding Children Board LGI Leeds General Infirmary MAST Multi-agency Support Team in CAF arrangements NOR Neonatal Outreach PCT Primary Care Trust SALT Speech and Language Therapist/Therapy SCH Sheffield Children’s Hospital SHA Strategic Health Authority

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Introduction

1.1 The requirement for Kirklees Safeguarding Children Board (KSCB) to carry out a Serious Case Review is detailed in Chapter 8 of Working Together to Safeguard Children: a Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (HM Government 2010) and in the Local Safeguarding Children Boards Regulations 2006.

1.2 The purpose of the Serious Case Review as identified in Working Together is to:

• Establish whether there are lessons to be learned from the case about

the way in which local professionals and organisations work together to safeguard and promote the welfare of children.

• Identify clearly what those lessons are, how will they be acted on and what is expected to change as a result.

• Improve interagency working and better safeguard and promote the welfare of children.

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1.3 In order to ensure the Serious Case Review identifies any lessons that should be learned and results in effective changes to protect children from harm, Working Together emphasises the importance of putting ‘the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings’ at the centre of the Review (HM Government 2010: 8.1). 2.0

Genogram recording family composition and relationships

2.1 It should be noted that in order to preserve the family’s privacy, potentially identifying information, including birth dates of family members and the gender of the child who is the subject of this Serious Case Review, have been omitted. Thus, this report has been written with publication in mind, whilst considering the need to balance the detailed information that is required to fulfil the purpose of a Serious Case Review and respect for the family’s feelings and their right to privacy. 3.0

Reasons for the Serious Case Review

3.1 At 12.40pm on 6/11/2010 the mother’s male partner made a 999 telephone call from a neighbour’s house, reporting that the child who is the subject of this Serious Case Review was choking after swallowing medication. A Yorkshire Ambulance Service rapid response vehicle arrived at the family home at 12.47 pm. and its team found the child lying naked on the hallway floor. Although it was past mid-day the living room curtains were drawn and the mother subsequently told an investigating officer from West Yorkshire Police that she and her partner had been asleep in bed when they were awakened by a loud bang and found the child collapsed on the bedroom floor. The chronology from the health visiting service (8/11/10) refers to a report from the Consultant Paediatrician at the mother’s local hospital, which indicates the child had been sleeping in the same bed as the mother and her partner.

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This was confirmed in the rapid response vehicle clinician’s referral to Kirklees Emergency Duty Team later on 6/11/10. The Mother also reported to the Police investigating officer that they had found an opened bottle of ‘PH UP’ (a caustic potassium hydroxide plant food) on the floor and presumed the child had drunk this. The bottle had been kept on a window ledge at the top of the stairs and was within the child’s reach. A chronology entry (6/11/10) notes information from Yorkshire Ambulance Service that the mother’s partner admitted knowing the bottle’s safety cap was loose. Although the Individual Management Review (IMR) from the Yorkshire Ambulance Service records the mother as telling attending staff that the child had not eaten for twenty-four hours, she is later reported in the West Yorkshire Police IMR as stating to an investigating police officer that the child had last eaten around midnight. 3.2 An ambulance subsequently attended at 12.54pm. As the ambulance was preparing to transport the child urgently to hospital, the Mother’s partner brought the bottle of ‘PH UP’ to the attention of a member of Yorkshire Ambulance staff who had accompanied the clinician in the rapid response vehicle. This was immediately shown to the rapid response vehicle clinician who quickly realised the child was not choking on tablet medication as had originally been thought, but had drunk liquid plant food. The child was taken to the local hospital for initial treatment and transferred to the paediatric intensive care unit at Leeds General Infirmary on the same day. The IMR from Leeds Teaching Hospitals records the child’s condition on admission as being ‘very poor’. 3.3 During the child’s stay at Leeds General Infirmary, the child underwent surgery on three occasions in response to the damage caused by swallowing corrosive plant food. Further surgery was required on 17/11/10 when a medical review concluded the child had a possible bowel perforation. Unfortunately the child did not survive this operation and died in the operating theatre. A Forensic Pathologist conducted a post mortem on 19/11/10 and concluded that the child’s death was due to complications arising from internal chemical burns in association with ingesting potassium hydroxide from the bottle of ‘PH UP’ plant food. 3.4 Following the child’s initial admission to the local hospital, the clinician from the Yorkshire Ambulance Service rapid response vehicle made a referral to the Emergency Duty Team at Kirklees Children’s Social Care with information about the child’s ingestion of plant food, medical condition and the mother’s report that the child had not eaten since mid-day the previous day. Staff from Leeds General Infirmary similarly made a referral to the Emergency Duty Team on the same day. The Consultant Paediatrician at the mother’s local hospital and Kirklees Children’s Social Care both contacted the West Yorkshire Police Child and Public Protection Unit on 6/11/10 to report this incident. West Yorkshire Police immediately started an investigation into the circumstances relating to the child’s hospital admission. On 8/11/10 Children’s Social Care Duty and Assessment decided that it would be appropriate to commence s. 47 enquiries under the Children Act 1989 (enquiries and assessment to ascertain whether a child is suffering or is likely to suffer significant harm and whether the local authority should take any action to safeguard or promote the child’s welfare).

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3.5 Prior to the incident which resulted in the child’s hospital admission on 6/11/10, several health and social care agencies/services had been working with the mother and her child for at least two and a half years. The child had complex care needs due to extreme prematurity and was profoundly deaf. These problems required paediatric follow-up to monitor the child’s health and development, neonatal support for the mother and child, health visiting and Audiology services. Additionally, Kirklees Children with Sensory Impairment Team helped the mother to understand the child’s additional social and communication needs in relation to deafness and provided a sign language tutor. Kirklees Children’s Social Care had knowledge about this family via the Common Assessment Framework (CAF) meetings held between December 2009 and November 2010. Staff from the Sure Start Children’s Centre also worked with this family. Professionals were concerned about the mother’s ability to manage the child’s complicated health needs and the consequences of the child’s profound deafness. The mother failed to consistently attend out-patient paediatric and Audiology/Hearing Clinic appointments and to be available for pre-arranged visits by professional practitioners. These problems were likely to have an adverse effect on the child’s social development, emotional wellbeing and educational achievement. 4.0

The Serious Case Review Process

4.1 Kirklees Children Safeguarding Board Serious Case Review Work-stream The Serious Case Review Work-stream is a standing Panel of KSCB and includes representation from NHS Kirklees (formerly the PCT), Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire Police, Children and Young People Service: Family Support and Child Protection, Kirklees Learning Services and Kirklees Council Commissioning. It is responsible for making recommendations to the Chair of KSCB about commencing Serious Case Reviews, making arrangements for conducting a Serious Case Review and monitoring the effective implementation of recommendations and related action plans arising from the Review Process. 4.2 The decision to undertake a Serious Case Review The Serious Case Review Work-stream met on 15 December 2010 to consider available information about the child, previous agency involvement with the family and whether events leading to the child’s death met the requirements for a Serious Case Review under paragraphs 8.9 to 8.12 of Working Together (HM Government 2010). A Serious Case Review must be arranged ‘when a child dies...and abuse or neglect is known or suspected to be a factor in the death’ (Working Together: 8.9). On this basis the Serious Case Review Work-stream recommended commencement of a Serious Case Review to the Chair of KSCB, and the Chair subsequently confirmed this recommendation on 20/12/10. The Serious Case Review Work-stream identified the terms of reference for the Serious Case Review and these were agreed by the Chair of the Safeguarding Board. 4.3 The Serious Case Review Overview Panel The Serious Case Review Work-stream arranged a panel of independent senior professionals from agencies in Kirklees to undertake the Serious Case Review.

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None of these professionals had any direct involvement in providing services to the child and family. It also identified an independent Chair for the Panel and an Independent author to write the overview report as required in Working Together (HM Government 2010: 8.16 and 8.33).This Panel is known as the Overview Panel. The independent Chair of the Overview Panel was Bron Sanders who was also the independent Chair of KSCB. The independent author was Dr Carole Smith who had no prior involvement with any of the agencies providing services to this family or with KSCB (other than in the capacity of an independent author). 4.3.1 Information about the Independent Chair of the Overview Panel

Bron Sanders holds a Social Work qualification (CQSW) gained in 1978, and Master of Business Administration (distinction), gained in 1998. She has over 30 years experience of children’s social care services in five Local Authorities, working initially as a social worker, but then managing fieldwork, hospital and residential services for children at a senior level, and ultimately at Head of Service level. She has considerable experience and expertise in relation to child protection services, and in leading children’s partnership bodies in strategic planning and service delivery and improvement. Currently, Bron Sanders is the Independent Chair for the East Riding and the Kirklees Safeguarding Children Boards, and also undertakes independent consultancy work for other authorities. Bron Sanders has not undertaken social work or management functions for Kirklees Council, and has had no involvement with this case prior to this Overview Panel.

4.3.2 Information about the independent author of the overview report Carole Smith’s qualifications are BSc (Sociology), M Phil (Social Work), Certificate of Qualification in Social Work, LLB, PhD. Carole Smith is an Honorary Senior Lecturer in the School of Nursing, Midwifery and Social Work at the University of Manchester. Between 1972 and 1994 she worked in the voluntary and statutory sectors as a social work practitioner, team leader and senior manager in services for children and families, including responsibility for child protection and safeguarding services. Her academic research, publications and teaching have concentrated on law, policy and practice in relation to statutory intervention with children and families, including issues associated with safeguarding children. Carole Smith has had no involvement with policy or practice matters relating to KSCB or this case and was therefore able to take an independent view of the Serious Case Review process with regard to the child and family concerned. 4.4 Membership of the Overview Panel The Overview Panel comprised the following membership:

• Bron Sanders – independent Chair • Assistant Director for Safeguarding Children and Vulnerable Adults and

Designated Nurse for Child Protection, NHS Kirklees • Consultant Paediatrician and Designated Doctor Child Protection, Calderdale

and Huddersfield NHS Foundation Trust • Named General Practitioner for Child Protection, NHS Kirklees • Chief Inspector Partnerships, West Yorkshire Police • Serious Case Review Co-ordinator for Kirklees Safeguarding Children Board

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• Acting Divisional Manager, Kirklees Children’s Social Care Children with a Disability Unit

• Head of Service for Kirklees Children’s Early Years Service • Clinical and Operations Lead for Kirklees Community Healthcare Services • Named Doctor for Child Protection, Mid-Yorkshire Hospitals NHS Trust and

Paediatric Consultant • Kirklees Safeguarding Children Board Manager

In attendance were:

• Dr Carole Smith, independent author • The legal advisor to Kirklees Safeguarding Children Board

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Terms of reference for the Serious Case Review

5.1 It was intended that this Serious Case Review would enable individual professionals and agencies to learn lessons about the way in which they had worked both individually and collectively to safeguard and promote the welfare of the child concerned. As far as possible, this Review was to be conducted in such a way that the process comprised a learning exercise for everyone who had been involved in the case. The terms of reference were developed in line with paragraph 8.20 of Working Together (HM Government 2010) and West Yorkshire Safeguarding Children Procedures, Chapter 10 (6.6). 5.2 Important issues in identifying learning from the Serious Case Review 5.2.1 From initial enquiries the Serious Case Review Work-stream of KSCB identified the following issues as requiring further investigation by the Overview Panel:

• Was there appropriate professional challenge with regard to parental behaviour and care of the child

• Was appropriate action taken by professionals to escalate issues and concerns regarding the child’s welfare

• Were services easily accessible to the child and mother • Were attachment issues between the child and mother appropriately

addressed by professionals (as the Serious Case Review progressed, the Overview Panel became concerned about this early presumption that attachment issues were significant in this case. The Panel therefore substituted the following wording: were there attachment issues between the child and mother and if so were they appropriately addressed by professionals)

• How was the active participation of the mother with services addressed and responded to by professionals

• How far did services/professionals understand and respond to the role of men in parenting and the life of this family

• To what extent was professional intervention with this family co-ordinated • Were professional reviewing and planning interventions effective in measuring

any progress in the quality of parenting that the mother provided for this child

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5.2.2 The Serious Case Review Work-stream confirmed that these issues might have to be revised as further information became available to the Overview Panel. In the event, the Overview Panel was satisfied that these major issues (but see change of wording above) and areas for potential learning adequately covered information arising from the Serious Case Review. 5.3 Individual Management Reviews (IMRs) 5.3.1 IMRs are reports from individual agencies/services that have had a significant degree of involvement with the child and family. They should aim ‘to look openly and critically at organisational and individual practice’ (HM Government 2010: 8.35), to determine whether improvements could be made and to identify how such changes should be effectively implemented to protect children from harm. In order to provide the Overview Panel with comprehensive information about this case, IMRs including detailed chronologies, were requested and received from the following agencies/services:

• Calderdale and Huddersfield NHS Foundation Trust with regard to services provided by the mother’s local hospital, Calderdale Royal Hospital, the neonatal outreach team, paediatric outpatient services and services for hearing impaired children.

• Kirklees Community Healthcare Services with regard to intervention by the General Practitioner and health visiting service.

• Kirklees Children’s Social Care with regard to services provided by the Children with Sensory Impairment Team, the Children with a Disability Unit, Sure Start Children’s Centre, the Child Care Inclusion Officer and Kirklees Information Sharing Service.

• NHS Kirklees health overview IMR with regard to the involvement of all health care practitioners and commissioning service

These agencies/services were requested to provide an account and analysis of their involvement with this family during the Review period as identified in the terms of reference. Agencies were also required to review records prior to the Review period and to include any relevant historical information about parents, carers and any other significant adults. 5.3.2 Additionally, it was recognised that other agencies/services had been involved with the child and mother to a relatively marginal degree. They were therefore requested to provide reports on their involvement for consideration by the Overview Panel. Reports were received from the following agencies/services:

• Kirklees Housing services • Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust • Sheffield Children’s Hospital, Sheffield Teaching Hospitals NHS Trust • The Mid Yorkshire Hospitals NHS Trust • West Yorkshire Police • West Yorkshire Probation Trust • Yorkshire Ambulance Service • The Child’s pre-school Nursery

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• Kirklees Home-Start

5.4 Period for review by the Serious Case Review 5.4.1 On considering initial information about this case the KSCB Serious Case Review Work-stream concluded that the appropriate time period to be covered by the Serious Case Review should be from confirmation of the mother’s pregnancy with the child to the child’s death on 17/11/10. However, the Serious Case Review Work-stream also recognised that historical information about the significant adults in this child’s life might help the Overview Panel to better understand their capacity for providing appropriate care to the child. IMR authors were therefore requested to include any relevant historical information about carers and other significant adults, which fell outside the time frame of the Serious Case Review. 5.5 Timescale for completing the Serious Case Review 5.5.1 It was initially intended in accordance with Working Together (HM Government 2010: 8.23) that the Serious Case Review should be completed and submitted to the Office for Standards in Education, Children’s Services and Skills (OFSTED) within six months from the Chair of KSCB confirming that a Serious Case Review should be completed. However, the Board Chair made this decision on 20/12/10 and due to the necessity for completion of IMRs and chronologies, the first meeting of the Overview Panel was not convened until 9 February 2011. Completion of the Serious Case Review was therefore delayed by approximately one month. OFSTED was notified about reasons for the delay. 5.5.2 At the time of conducting the Serious Case Review the child’s mother was on police bail pending criminal prosecution for child neglect. Communication between the Overview Panel and West Yorkshire Police indicated that no additional information was likely to emerge from the criminal trial other than that already available from the IMRs and the West Yorkshire Police report prepared for the Panel. This view was confirmed when a Police investigating officer attended the Overview Panel meeting on 18/5/11. The Panel therefore decided that completion of the Serious Case Review and its submission to OFSTED should not be influenced by the timing of criminal proceedings. However, the Panel was aware that its intention to involve family members with the Serious Case Review, and publication of the overview report and Executive summary, would be dependent on completion of criminal proceedings against the child’s mother. Should any relevant information emerge from criminal proceedings and/or subsequent conversations with family members, the Overview Panel agreed that it would re-convene and if necessary the independent author would prepare an addendum to this overview report. 5.6 Involvement of family members in the Serious Case Review 5.6.1 The Overview Panel considered it was important for representatives to meet relevant family members to explain the purpose of a Serious Case Review, to invite their views on services which had been provided and their effectiveness in helping the family and to discuss any issues which might arise from publication of the overview report and Executive Summary. It discussed this matter at its meetings on 9/2/11, 24/3/11 and 20/4/11.

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5.6.2 At its meeting on 24/3/11 the Overview Panel concluded it would be most beneficial to include the child’s mother, her grandmother who appeared to have played an important role in her and the child’s life, and the child’s father who was in a relationship with the mother for a significant period covered by the Serious Case Review. The Chair of the Overview Panel would write a letter inviting their participation, which it was planned, would be delivered and explained to the family by their Police liaison officer. If family members agreed, the independent author and Serious Case Review Co-ordinator for KSCB would arrange to meet them. 5.6.3 The Overview Panel consulted with West Yorkshire Police about the viability of interviewing these family members given that the mother was due to be prosecuted for neglecting her child. The Crown Prosecution Service subsequently conveyed the view that it would be inappropriate to contact the child’s mother or any potential witnesses prior to completion of criminal proceedings (see also paragraph 5.8.3). Invitations for family members to meet representatives of the Overview Panel would therefore be delayed until criminal proceedings had been concluded 5.7 Legal advice to the Overview Panel 5.7.1 The legal advisor to KSCB attended meetings of the Overview Panel and provided legal advice as appropriate. 5.8 Parallel Investigations of practice 5.8.1 The Coroner’s inquest into the death of this child was adjourned until completion of criminal proceedings against the mother. The Chief Inspector Partnerships, West Yorkshire Police, as a member of the Overview Panel, was designated to liaise with the Coroner’s Office on behalf of the Panel 5.8.2. West Yorkshire Police Homicide and Major Enquiry Team initiated investigations into circumstances leading to the hospital admission and subsequent death of this child. They later charged the mother under s. 1(1) of the Children and Young Persons Act 1933 with child neglect and the Crown Prosecution Service decided that criminal proceedings should follow. This section of the Act reads:

If any person who has attained the age of sixteen years and has responsibility for any child or young person under that age, wilfully assaults, ill-treats, neglects, abandons, or exposes him, or causes or procures him to be assaulted, ill-treated, neglected, abandoned, or exposed, in a manner likely to cause him unnecessary suffering or injury to health (including injury to or loss of sight, or hearing, or limb, or organ of the body, and any mental derangement), that person shall be guilty of a misdemeanour.

5.8.3 When the Overview Panel was considering this case the mother remained on Police bail pending prosecution for child neglect. The Chair of the Panel wrote to the West Yorkshire Police Senior Investigating Officer on 8/6/11 formally requesting their agreement to the Panel inviting family members to participate in the Serous Case Review. This letter drew attention to Guidance endorsed nationally by the Association of Chief Police Officers and the Crown Prosecution Service (CPS and ACPO 2011) which notes that interviews, as part of the Serious Case Review

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process, with witnesses or with individuals who are suspected of or charged with an offence should not automatically be precluded because of ongoing criminal proceedings. The Guidance recommends that the Senior Investigating Officer should explain in writing to the Overview Panel Chair the reasons for any proposed restriction of activities which are required for completion of a Serious Case Review. In this case, following consultation with the Crown Prosecution Service, the Senior Investigating Officer wrote to the Panel Chair requesting that family members should not be approached until the completion of criminal proceedings. This impeded the Panel’s wish to involve the mother and other significant family members in the Serious Case Review, and ongoing criminal proceedings delayed publication of the overview report and the Executive Summary until conclusion of the criminal case. Correspondence between the Overview Panel Chair and the West Yorkshire Police Senior Investigating Officer is attached to this report. 5.8.4 The Strategic Health Authority (SHA) has a responsibility to evaluate and manage performance arrangements for safeguarding children from harm. Primary Care Trusts (PCTs) must report individual safeguarding children cases to the (SHA) through the serious incident process, which in this case is regulated by the NHS Yorkshire and Humber procedure for the management of serious incidents. The child’s death was recorded as being a serious incident by NHS Kirklees and the SHA was notified accordingly. Thereafter, the serious incident and the Serious Case Review processes were co-ordinated within the same time frame. This required the PCT commissioner to provide feedback to the SHA as follows: Week six from notification of the serious incident

: send terms of reference for the Serious Case Review to the SHA. Week twenty-four from notification of the serious incident

: submit copy of PCT Health overview report and action plan prepared for the Serious Case Review to the SHA. Week twenty-seven from notification of the serious incident:

The SHA agrees closure of the serious incident process when all elements of the action plan have been implemented.

SHA provide feed-back to the PCT commissioner on the Health overview report and action plan.

Approximately thirty-five weeks from notification of the serious incident

: send the SHA a copy of the Serious Case Review Executive Summary and OFSTED’s evaluation of the PCT Health overview report and action plan.

5.9 Management of family, public and media interest following the Serious Case Review 5.9.1 The Overview Panel was committed to encouraging appropriate family members to participate in the Review process, but had to delay this until the completion of criminal proceedings involving the child’s mother. However, the Panel intended prior to and following publication of the overview report and Executive Summary, to discuss the Serious Case Review process and its findings with family members in a supportive and sensitive manner. 5.9.2 The Overview Panel had access to support and advice from Kirklees media relations and intended to consult with media contacts in relevant agencies to develop

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an appropriate strategy for managing the publication of the overview report and Executive summary should the need arise for this 6.0

Methodology for conducting the Serious Case Review

6.1 Briefing sessions for IMR authors were held on 18/1/10, which the independent author attended. IMR authors were required to prepare their reports in accordance with guidance from KSCB and an on-line pro-forma was provided to assist with the preparation of these reports. The guidance made it clear that IMR authors should interview relevant members of staff to clarify or to seek further information about the case and the completed IMRs make it clear that this was done. 6.2 The Overview Panel met on the following dates: 9 February 2011 23 March 2011 24 March 2011 20 April 2011 21 April 2011 18 May 2011 8 June 2011 6.3 The IMRs were initially quality assessed on 28/2/11 by the independent author, the Chair of the Overview Panel, the KSCB Manager and the Serious Case Review Co-ordinator for KSCB and feedback was provided to the authors. Subsequently, IMR authors attended meetings of the Overview Panel on 23 and 24 March 2011 where Panel members were able to seek clarification, obtain further information and request further work to ensure that the IMRs provided a full account of agencies’ intervention with this family and appropriate analysis. 6.4 The independent author attended all meetings of the Overview Panel and thus had access to its discussions and conclusions. Additionally, as so many of the IMRs made reference to a lack of clarity in decision making and planning during CAF meetings, the independent author requested and was provided with the initial CAF assessment and minutes of CAF meetings. The Overview Panel was concerned to understand the implications of profound deafness for the child’s social and cognitive development and the relationship between speech and signing in enabling effective communication. It had an opportunity to discuss these issues when the Advisory Teacher for the Hearing Impaired from Kirklees Children with Sensory Impairment Team attended the Panel meeting on 18/5/11. The Panel considered whether any further expert advice was necessary to inform the Serious Case Review and concluded it was not. 6.5 Members of the Overview Panel agreed to ensure that relevant managers would provide professional staff who had worked with this family with individual support and feedback about the Serious Case Review process and its findings at a point between completion of the Serious Case Review and publication of the overview report and Executive Summary. Additionally, to enhance learning, the Safeguarding Co-ordinator for KSCB would arrange a discussion/feedback meeting with staff involved

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in the case following completion of the Serious Case Review. Independent authors are routinely invited to these meetings. 6.6 The IMR authors and the author of the overview report have included references to appropriate research, national evaluations of Serious Case Reviews and other literature where this is helpful in providing background and supporting information. Additionally, the IMRs and overview report take account of learning which has been identified from other Serious Case Reviews completed by Kirklees Safeguarding Children Board and any implications it may have for this Review. 6.7 Paragraph 8.43 of Working Together requires the Safeguarding Board’s Serious Case Review Sub-Committee (in this case the Serious Case Review Work-stream) to quality assure the final Review. Quality assurance was accomplished through membership of the Overview Panel by the independent Chair and the Deputy Chair of KSCB. The latter was also the Chair of the Serious Case Review Work-stream and reported progress of the Review to Work-stream meetings held on 19/1/11, 7/4/11 and 23/5/11. 6.8 The overview report, Executive Summary, IMRs and action plans were considered and approved by KSCB at its meeting on 13 July 2011.

7.0 Implementation of Multi-Agency Action Plans

7.1 A list of recommendations generated by this Serious Case Review is included at the end of the overview report and a multi-agency action plan is attached as an appendix. The Serious Case Review Work-stream of KSCB has responsibility for monitoring the implementation of action plans across agencies/services and reporting on progress to the KSCB. The KSCB has now introduced a post of Serious Case Review Co-ordinator and part of this role is to actively check on how effectively agencies/services are implementing the multi-agency action plan, to identify any problematic aspects of implementation, to support progress in this context and to report to the Serious Case Review Work-stream. 8.0

Ethnic, cultural and equalities issues that may be relevant to professional practice and conduct of the Serious Case Review

8.1 Paternity, ethnicity and cultural issues 8.1.1 Knowledge about the child’s paternity only became apparent later in the child’s life, as early midwifery and health visiting services did not record the identity of the child’s father. It was difficult for IMR authors to ascertain whether midwifery and health visiting staff had requested this information from the mother and whether she had refused to provide it, although the IMR author for Calderdale and Huddersfield NHS Foundation Trust told the Overview Panel that midwifery staff would have asked for details about the child’s father and the mother must have declined to answer. The mother’s response, however, is not included in midwifery records made at the time. The IMRs indicate that health visitors, neonatal outreach nurses, professionals from the Children with Sensory Impairment Team and staff from the Children’s Centre were never aware of any paternal involvement with the family.

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However, although chronologies from three acute hospitals, out-patient departments and the GP frequently refer to ‘father’/’Dad’ and ‘parents’ making hospital visits to see the child and to ‘parents’ attending appointments, the father’s identity and/or ethnicity was not recorded. 8.1.2 When the child was admitted to Sheffield Children’s Hospital at nearly two months old, hospital staff recorded the father’s name and age (not his date of birth). However, the Overview Panel was unable to confirm whether this man was the same individual who was later identified as the father following the child’s death, since the name recorded for him by Sheffield Children’s Hospital does not match that given by the ‘father’ to West Yorkshire Police. The Sheffield Children’s Hospital and West Yorkshire Police IMRs provide the same age for the person(s) identified in their respective records as being the child’s father. Nevertheless, following the child’s death the Police IMR records a statement from a man who identified himself as the child’s father and was identified as such by the child’s mother. This man told Police he had maintained a relationship with the child’s mother for about six years, until about January 2010. During the first year of the child’s life had seen his child and the mother every day, but he did not live in the mother’s home. From this information the Overview Panel reasonably concluded that the person who was recorded as the father by Sheffield Children’s Hospital and by West Yorkshire Police was the same individual. Reference to the mother’s former partner in this overview report therefore includes the presumption that this person is also the child’s father. 8.1.3 Further enquiries conducted by the Serious Case Review Overview Panel yielded somewhat inconclusive and contradictory results regarding the child’s and mother’s race/ethnicity. When the child was admitted to Leeds General Infirmary at five days old the child’s ethnicity was recorded in the category ‘any other mixed race background’. The IMR notes that this definition would usually have been obtained from the child’s carer. The child’s subsequent admission to Sheffield Children’s Hospital prompted staff to commence a Common Assessment Framework (CAF) assessment because the child was considered to have additional needs and his mother was single, relatively young and living with extended family members in overcrowded conditions. The partially completed CAF records the mother’s and child’s ethnicity as ‘mixed’ although it is not known how this was determined. A CAF assessment was later completed in November 2009 and here the child’s ethnicity is recorded as Pakistani/Iranian, referring to the mother’s former partner and the mother’s ethnic origins respectively. When the child was admitted for the second time to Leeds General Infirmary following ingestion of plant food, the mother defined the child’s ethnicity as ‘White/Black Caribbean’. The mother and father self-defined their ethnicity to West Yorkshire Police as British/Asian and White British/Asian respectively. Clearly, this leaves some uncertainty about the child’s ethnic origin although the mother’s former partner, who is presumed to be the father, and the mother’s ethnicity suggest that the child was of White British /Asian origin. The Panel reasonably concluded that the mother’s ethnicity was White British/Iranian. 8.1.4 A child and parents’ ethnicity may have important implications for their cultural attitudes and the provision of ethnically sensitive services. Although the mother and father’s ethnic background was not recorded by the health visitor, it is not known whether this information was requested. However, the health visiting service had two further opportunities to pursue information about the child’s ethnicity, arising

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from. Two pieces of information, which should have alerted the health visitor to further investigate the mother and child’s ethnicity. 8.1.5 It is clearly important that professionals working with a family should be able to identify significant family members/carers and to consider whether their ethnicity has implications for cultural attitudes and the related appropriateness of professional practice and service delivery. The Overview Panel was assured by the IMR authors for Calderdale and Huddersfield NHS Foundation Trust and Kirklees Community Healthcare Services that midwives and health visitors are now required to record, if possible, details about paternity and a child’s ethnicity at their initial contact with the mother. This requirement was not in place at the time of this child’s birth. The IMR from Kirklees Community Healthcare Services also includes a recommendation that GP records must document the identity of all persons present at a consultation regarding a child, and their relationship to the child. 8.1.6 The mother’s, father’s and child’s religion were not recorded by any of the professionals working with this family. The IMR from Calderdale and Huddersfield NHS Foundation Trust notes that this question was routinely asked at the time of the mother’s maternity booking and she must have declined to answer. The Overview Panel was unable to ascertain whether professionals from other agencies asked this question, whether an answer was declined or, as is probable, that religion did not play a significant part in this family’s life. 8.1.7 While concerned that professionals had not made greater efforts to accurately record the identity of this child’s father and the child’s ethnicity, the Overview Panel and independent author of the overview report concluded there was no evidence to suggest that ethnicity, religion or cultural issues were, or should have been, significant factors in relation to professional practice, service delivery or the Serious Case Review process. 8.1.8 There was no evidence of any linguistic issues regarding the child’s parents, which might or should have influenced the nature of professional intervention in this case. However, the child was profoundly deaf and this had significant implications for language development and communication. 8.2 Equality issues and marginalisation 8.2.1 In terms of equality issues, the child who is the subject of this Serious Case Review was diagnosed with a profound hearing impairment shortly after birth. As a profoundly deaf child, the child was, by definition, a disabled child in need under s. 17(11) of the Children Act 1989. This means that the child required local authority services to enable ‘a reasonable standard of health and development’ and to ensure that the child could achieve the five outcomes in Every Child Matters (Chief Secretary to the Treasury 2003). 8.2.2 It is important to recognise that deaf children may be particularly vulnerable in terms of their emotional and social wellbeing and life chances. As a group, they are twice as likely to be abused as their hearing peers (Sullivan et al 2000) and at least 40% will experience mental health problems in childhood or early adulthood compared to around 25% of their hearing counterparts (Department of Health 2005).

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The Department of Health (2005) also points out that ‘deafness for many people is associated with social exclusion and reduced educational and employment opportunities’, factors that are closely related to mental ill health (Social Exclusion Unit 2004). Research indicates that deaf children are likely to lag behind hearing learners in their reading ability and to a lesser extent in mathematical achievement (Powers et al 1998; Department of Health 2005). Given that deafness is more prevalent in disadvantaged and ethnic minority groups (Department of Health 2008a), deaf children may experience the impact of interacting factors that contribute to marginalisation and social exclusion. It is for these reasons that some academics, researchers and practitioners have not only emphasised the importance of language development, communication skills and learning but have directed attention to the social and emotional world of deaf children/adults where issues of self-esteem, identity and culture have a significant impact on wellbeing and life outcomes. While deaf children generally receive a well developed service from learning/education and Audiology/health specialists, it is far less likely that social care specialists will recognise and respond to their social and emotional needs or that they will receive an assessment as children ‘in need’ under s. 17 of the Children Act 1989 (Department of Health 2005; Department of Health 2008a and 2008b; Young et al 2008; Young et al 2010). 8.2.3 There was no evidence from observations of relevant professionals that the issues discussed above had significantly affected the experiential quality of this child’s short life. However, it was evident that potential problems were showing early signs of emerging. For example, in late 2009 the CAF assessment records the child’s frustration about difficulties in communicating needs/wishes and in response to an inability to understand the mother’s explanations about behavioural boundaries. The Advisory Teacher for the Hearing Impaired told the Overview Panel that the child had delayed language and communication skills compared to expectations for deaf children of a similar age. It will become evident from this report that while the child and mother received appropriate services from learning and Paediatric Audiology/Health specialists in response to the child’s additional needs, they were not offered a social care assessment or services under s. 17 of the Children Act 1989 for children ‘in need’. 8.2.4 The Overview Panel and the independent author concluded that issues associated with the parents’ and child’s ethnicity, culture and religion were not significant in relation to professional intervention and service delivery or to the Serious Case Review process. However, the child’s profound deafness constituted a social equality issue and was central to the Overview Panel’s consideration of professional intervention and service provision. 8.3 Material resources 8.3.1 The child’s mother was unemployed and in receipt of financial benefits for the duration of the Serious Case Review. However, during a CAF meeting on 8/3/10 the mother was asked if she had any financial difficulties and responded that she was able to manage her income and expenditure. There is evidence that the child’s mother was helped to maximise her child’s wellbeing through, for example, encouragement to register her child’s birth so that she could claim appropriate tax

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credits and health visiting support to apply for Healthy Start vouchers which would provide her with free milk, fruit and vegetables. 8.3.2. The IMRs do not provide any information about the extent to which the child’s father may have financially supported the mother. However, the Overview Panel was satisfied that financial issues did not play a significant part in the mother’s capacity to care appropriately for her child. 8.3.3 The mother had accepted a Council tenancy in a two bed-roomed house by the time her child was discharged from hospital in April 2008. She was reported to be happy with this accommodation, which the mother reported was not far from members of her extended family. 8.4 Extended family relationships and support 8.4.1 The IMR from Kirklees Directorate of Children and Young People notes that, the child’s mother lived with her maternal grandmother for significant periods of time during her formative years. A chronological entry (7/1/08) from the health visiting service records the mother as living in overcrowded conditions with her grandmother and Uncle upon discharge from hospital following the child’s birth. There are further references in the chronology to the mother and her sister visiting the child in hospital (13/1/08), the mother and her grandmother visiting (24/1/08; 23/2/08) and the father and his brother visiting (5/2/08). Chronological entries show that the child’s father frequently visited the child in hospital. When the child was later admitted to Leeds General Infirmary in November 2010, the child’s mother, her grandmother and her sister were in attendance. 8.4.2 The CAF assessment completed in November 2009 refers to the mother’s grandmother as providing support and advice. The Advisory Teacher for the Hearing Impaired reported that she had occasionally met the mother’s grandmother, aunt and mother during home visits. IMR narratives and chronologies provide brief glimpses of the child’s father and members of the child’s extended family. However, there is no coherent information about the role these significant adults played in the mother and child’s life. Professionals recognised the child as having additional needs and the challenges that this presented to the mother. It is surprising, therefore, to find no evidence of professional persistence in properly assessing the nature and extent of actual and potential support from extended family members. 9.0

Social and emotional history of parents/carers

9.1 Under the terms of reference in Working Together (HM Government 2010: 8.20) the Serious Case review is required to consider ‘what family history/background information will help to better understand the recent past and the present’. National evaluations of Serious Case Reviews and research (Department of Health et al 2000; Brandon et al 2008; Brandon et al 2009; Howe 2005; Milner and O’Byrne 2009) have made it clear that an understanding of parents’/carers’ own social, emotional and parenting history is important in any assessment of their capacity to care appropriately for a child.

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9.2 The mother did not volunteer much information to professionals about her own background and family life. During the uncompleted CAF assessment by staff at Sheffield Children’s Hospital, the mother reported that she had been involved with statutory services three years earlier but no further details were recorded. The first health visitor allocated to the family completed a Universal Needs Assessment on 7/1/08 during a home visit. This check-list assessment noted information from the mother about her poor school attendance and her view that most people could not be trusted. 9.3 Information from relevant IMRs indicates family difficulties whilst mother was growing up. Kirklees Children’s Social Care records identify four referrals in 2003 concerning family difficulties and note that mother spent a significant amount of time in her grandmother’s care. The report from Sheffield Children’s Hospital and the IMR from Kirklees Community Healthcare Services confirm that the child’s mother was living with her maternal grandmother during her pregnancy. Although further details about the mother’s family history and her behaviour were available to the Overview Panel, the Panel and the independent author considered that their inclusion in the overview report would constitute an unnecessary invasion of her privacy and would not be appropriate for publication. Nevertheless, it was clear that the child’s mother was vulnerable and her parenting capacity may have been compromised by her own problematic experience of family life. However, agencies/services working with this family had, at the time, very limited knowledge and understanding about this mother’s own social and emotional history and experience of being parented. When the CAF assessment was completed in November 2009, the child’s mother stated there were no issues associated with her family history and there is no evidence to suggest that professionals explored this any further. 9.4 The Overview Panel had information from relevant IMRs about the histories of the mother’s former partner (the child’s father) and her current partner at the time of the child’s death, but considered that its inclusion in the overview report was not necessary for achieving an understanding of events and associated professional intervention in this case. The Panel and the independent author agreed that reference to such detailed information would not be appropriate for publication. However, one event regarding the mother’s former partner was relevant for constructing a picture of the mother’s relationships and family life during the Serious Case Review period. The West Yorkshire Police IMR records a disagreement between the mother and her former partner’s relationship was ending. The disagreement was resolved and the police took no further action. 9.5 Professionals working with the family had only their own observations and records, very limited information from the mother (that she had a poor school attendance record, distrusted people and had been involved with statutory services) and a brief CAF assessment to guide their intervention and understanding of the mother’s parenting capacity. They had virtually no information about the extended family and none about the mother’s male partners. In November 2008 the Family Support Worker from the Children’s Centre contacted Children’s Social Care Duty and Assessment service to enquire whether anything was known about the child’s mother after the health visitor had indicated there may have been some past involvement. Duty and Assessment reported four referrals in 2003 regarding family

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difficulties but gave no further information. Kirklees Children’s Social Care clearly held historical information about the mother that should have enabled professionals to better understand her own experience of family life, possibly her lack of trust and resistance to professional intervention and her parenting capacity. There is no evidence (apart from the Family Support Worker’s contact with Duty and Assessment) that professionals thought historical information was relevant. Additionally the basis for intervention and assessment was the CAF with reference to a child having additional needs. The CAF is a relatively brief first level assessment and it is not designed for the kind of in depth assessment and analysis expected from core assessments of children in need under s. 17 of the Children Act 1989 or s.47 child protection enquiries. 10.0 The policy and practice context 10.1 Local changes in agencies’ policy and practice during the period covered by the Serious Case Review are noted at appropriate points in this overview report. 10.2 At the beginning of the Review period (late December 2007) professionals, particularly in universal services, were concerned to identify those children with additional needs who were unlikely to achieve the five outcomes in Every Child Matters (Chief Secretary to the Treasury 2003). The CAF assessment was the means through which such children could receive early intervention by way of a relatively brief and preliminary multi-agency assessment and the provision of appropriate services (see Children’s Workforce Development Council 2007a and 2007b). The IMRs clearly identify professional concern about the child’s developmental opportunities in the context of Every Child Matters and professionals’ attempts to improve these. Current Government policy similarly emphasises the effectiveness of early intervention both in terms of a child’s age and the early identification of potential difficulties/social disadvantage (HM Government 2011a and 2011b; Munro 2011, Chapter Five). 10.3 Where children were identified as likely to be ‘in need’ (of services) under s. 17 of the Children Act 1989 or were subject to child protection enquiries under s. 47 of the Act and required an in-depth core assessment, this was completed in accordance with statutory guidance in the Framework for the Assessment of Children in Need and their Families (Department of Health et al 2000; Department of Health 2000). These arrangements extended throughout the Review period. 10.4 The 2006 version of Working Together to Safeguard Children was operational at the beginning of the Review period. This was replaced in March 2010 by the current edition of Working Together. 11.0 The child at the centre of the Serious Case Review 11.1 The Overview Panel was mindful about advice in Working Together that the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings should be at the centre of the Serious Case Review. This was a necessary reminder since national evaluations of Serious Case Reviews had noted the way in which children tend to become ‘invisible’ to those professionals working with families and in the Serious Case Review process (Rose and Barnes 2008; Brandon et al

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2009; OFSTED 2008; 2009; 2011). There was evidence that too often professionals did not get to know children and failed to talk to them or to sufficiently ‘see’ them. Professionals thus failed to understand children’s experiences, perspectives, wishes and feelings. 11.2 The child who is the subject of this Serious Case Review was not yet thee years old when he/she died, and had delayed language development and communication skills. It would thus not have been possible for professionals to explore this child’s world through direct communication with the child. However, the health IMR narratives and chronologies contain observational records describing the child’s wellbeing and the child’s interaction with professionals and the mother. The report from the child’s pre-school nursery provides a vivid picture of a happy, inquisitive, active and outgoing child – the child presented as a person rather than simply as an ‘object of concern’ (Butler-Sloss 1988: 245). The child’s wellbeing and characteristics are discussed at appropriate points throughout this overview report and derive from professionals’ observations of and interaction with the child. 12.0

Description and Analysis of Individual Management Reviews

12.1 There are clearly numerous ways of organising information from the IMRs and presenting the overview report. However, I decided that clarity would best be afforded by a yearly description of events followed by an analysis relating to each year. An overview analysis attempts to bring issues, learning and recommendations together towards the end of this overview report (see paragraphs under 21.0). 13.0

Descriptive account of Year 1: July 2007 to end of December 2007

13.1 The mother attended all her antenatal appointments up to the point of the child’s premature birth at 26 weeks gestation and the Community Midwife made a home booking visit early in the pregnancy to complete an initial assessment of health, social and welfare needs. The IMR author for Calderdale and Huddersfield NHS Foundation Trust (CHFT) told the Overview Panel there was evidence that the Midwife had enquired about paternity, but the mother had declined to answer. This was not, however, recorded and the relevant part of the booking form was left blank. Although the IMR author notes that information about religion was routinely sought at maternity bookings, the mother’s religion was not specified. A Midwifery Assistant also visited the mother, at the Midwife’s request, with regard to her housing needs as she was living with her grandmother in overcrowded conditions and was applying for re-housing. The Community Midwife made an appropriate referral to the health visiting service. 13.2 In late 2007 the Mother was admitted to her local hospital and transferred to Calderdale Royal Hospital (CRH) for the premature birth of her only child. Details of paternity were not recorded at this time. The child remained on the Special Care Baby Unit until at five days old the possibility of a perforated bowel necessitated the child’s transfer to Leeds General Infirmary (LGI). On admission to LGI the child’s ethnicity was recorded as ‘any other mixed race background’. 13.3 The mother attended her GP practice twice in the period prior to her child’s birth for routine appointments associated with her pregnancy. The GP received

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notification of the child’s premature birth and subsequently of the child’s transfer from Calderdale Royal Hospital to LGI. 14.0

Analysis of Year 1: July 2007 to end of December 2007

14.1 The provision of GP and Midwifery services and referral to the health visiting service were undertaken appropriately, although midwifery involvement was more limited than usual due to the child’s premature birth. Records indicate that the mother and her baby received appropriate community and acute hospital care. 14.2 The IMR from Kirklees Community Healthcare Services (KCHS) indicates that the Midwifery referral to the Health Visiting service did not include a detailed assessment or any vulnerability issues associated with the mother’s current circumstances. However, at that time there was nothing to suggest to the Community Midwife that the mother was significantly vulnerable or had any social or emotional needs that might impact on the baby’s wellbeing. The IMR from KCHS notes that administration of a pre-CAF checklist by Midwifery Services will be standard practice across Kirklees by 2011. This should enable Midwifery services to identify any maternal/paternal vulnerability, including in this case the mother’s relatively young age, single status and housing needs and should direct attention to any early risk of potentially poor outcomes for the child. A pre - CAF checklist would prompt early health visitor antenatal contact if additional social needs had been identified. 14.3 A chronology entry (17/12/07) indicates that the first health visitor (HV1) knew about the child’s transfer to LGI with a suspected perforated bowel and on the same day as this transfer sent a standard pro-forma letter to the mother arranging an appointment. The IMR author from KCHS is critical that, under the circumstances, HV1 did not send a more personal letter which was sensitive to the family’s difficult circumstances. This criticism may be valid, but in my view it is an unfortunate consequence of a professional reliance on standard pro-forma means of communication that individual professionals are not encouraged to think beyond these requirements. 14.4 The chronology records good inter-professional communication during this period insofar as the health visitor (HV1) maintained contact with acute hospital services about the child’s progress. 14.5 As has been noted, it is important that Midwifery staff try, as far as possible, to ascertain details about the child’s paternity and ethnicity and that they accurately record parental responses. Midwives who have early contact with a prospective mother are required to try and collect this information and to ensure that parental responses are recorded. 15.0

Descriptive account of Year 2: January 2008 to end of December 2008

15.1 Following surgery at LGI for a perforated bowel and twenty days in-patient care, the child was transferred to the neonatal unit at the mother’s local hospital. The report from Leeds Teaching Hospitals NHS Trust notes that the mother visited her child on eight days during the child’s admission to LGI.

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15.2 HV1 visited the child’s mother at her grandmother’s home on 7/1/08 following her hospital discharge. Health visiting records indicate the house was clean and warm but overcrowded. The mother reported that she had applied for re-housing but had heard nothing and HV1, with the mother’s permission, sent a supportive letter to Kirklees Housing Services shortly after this visit. During this visit HV1 completed a tick-box questionnaire known as the ‘Universal Needs Assessment’, which was designed to identify basic information about a family’s health and social needs. The IMR from KCHS notes that the assessment identified the mother’s previous poor school attendance and her feeling that most people could not be trusted. HV1 recorded the mother’s statement that she was no longer in a relationship with the child’s father. The KCHS chronology entry (7/1/08) indicates there was no record of any discussion about paternity, the father’s involvement with the child or the child’s ethnicity in HV1’s records. It was not standard practice for health visitors to record details of ethnicity at that time. HV1 planned a second visit following the child’s discharge home from hospital. The chronology (7/1/08) records that HV1 completed a Children’s Centre Registration form with the mother as required by arrangements for integrated service provision. 15.3 Between the beginning and end of January 2008 the chronology records that the child received appropriate care at the mother’s local hospital. During this period the CHFT chronology records that the mother visited her child on six occasions, including one visit with her sister and one with her grandmother. The chronology additionally records nineteen visits by the child’s ‘parents’ and an absence of visits on only four days. On one occasion the mother visited during the early hours of the morning (chronology entry 21/1/08) and on another occasion both parents visited around this time (chronology entry 28/1/08). The chronology indicates that during at least eight of these visits the ‘parents’ were involved in providing practical care for the child. However, on 30/1/08 the child was transferred to Sheffield Children’s Hospital (SCH) because of the child’s deteriorating condition. At that time the chronology (30/1/08) records that the ‘parents’ were with the child just prior to transfer and intended to visit the child at SCH later that evening. The child remained at SCH until 11/2/08 and was then transferred back to the mother’s local hospital. 15.4 During the child’s admission to SCH, chronology entries from Sheffield Teaching Hospitals NHS Foundation Trust indicate that the child’s mother or ‘parents’ spent time with the child for the majority of the time. The mother stayed at SCH, although the chronology is not explicit about the duration of this arrangement. Chronological entries suggest there was no parental contact with the child on 3/2/08 and 6/2/08. On 11/2/08 the Sheffield Teaching Hospitals NHS Trust chronology records that the mother visited and cuddled her baby over an extended period. 15.5 On admission to SCH, the child’s father’s name and age were recorded. While the child was being cared for at SCH, staff began to complete a CAF assessment. This recorded the mother’s previous involvement with local statutory services and her residence with her grandmother, uncle and cousin in overcrowded conditions. The report from Sheffield Teaching Hospitals NHS Trust indicates that this information prompted staff to discuss the mother’s housing circumstances with Midwifery and health visiting services for the mother’s local area. However, the chronology indicates that staff from SCH did not relay their concerns about the

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mother’s housing needs to the Community Midwife and HV1 until the child’s discharge on 11/2/08. Only the health section of the CAF assessment was completed. Contact between the SCH Neonatal Unit Child Protection Liaison Nurse, HV1 and the Community Midwife is recorded in the CHFT chronology (11/2/08), but was not documented by SCH. 15.6 The child was transferred from SCH back to the mother’s local hospital on 11/2/08 and remained there for nearly ten weeks. During these sixty-nine days, the chronology records visits from the mother and frequently from the ‘parents’ on all but five days. On each of these five days one or both parents visited in the very early hours of the following morning. Although chronological entries do not always note the length of these visits, it is evident that the mother sometimes stayed at the hospital all day or for several hours. The mother is reported in the chronology to have fed, bathed or provided other practical care for her baby on thirty-six of the sixty eight days, although I suspect that this underestimates the extent of her involvement. Numerous parental visits occurred during the night and despite chronological entries noting the parents were able to feed the baby on many of these occasions, the CHFT IMR reports that staff encouraged the mother to visit for longer periods during the day so she could play a greater role in her baby’s care. When the CHFT IMR author interviewed staff at the mother’s local hospital, it became apparent that they had thought the nature of the father’s employment explained his and the mother’s late night visits. 15.7 SCH had informed HV1 and the Community Midwife about the mother’s housing needs in early February 2008, although HV1 was already aware of this from her home visit on 7/1/08. By 3/3/08 the mother had heard nothing from Kirklees Housing Services and on expressing her concern to nursing staff at her local hospital they contacted Housing on her behalf. Kirklees Accessible Homes Team (KAHT) recorded the referral on 3/3/08. The mother’s grandmother subsequently contacted HV1 to say that the accommodation initially offered was inappropriate. HV1 contacted Housing on the mother’s behalf to explain her reluctance about accepting this property. On 27/3/08 the Senior Medical Advisory Officer (Housing) visited the mother at her grandmother’s home and helped her to complete the self-assessment form. On 31/3/08 the mother was offered a two bedroom house with level access and was happy to accept this tenancy. The mother concentrated on decorating, cleaning and preparing the house for her child’s impending discharge from hospital. On 15/4/08 a neonatal outreach (NOR) nurse visited the house but considered it was not yet suitable for the child’s discharge. At a further visit on 19/4/08 the NOR nurse observed that the house was clean, warm and appropriately equipped. The child was discharged home to the mother’s care on 20/4/08. 15.8 Prior to the child’s discharge home, the mother had stayed at her local hospital overnight on 13/4/08 and attended to all her child’s needs. Nursing staff at the hospital had supported the mother in learning how to prepare feeds and administer her child’s medication and had advised her on relevant matters regarding her child’s health and care requirements. A chronology entry on 15/4/08 indicates that nursing staff had no concerns about the mother’s overnight care of her baby and that she was ‘competent’ in making feeds and administering the baby’s medication. On 7/4/08 nursing staff at the hospital had advised the mother that she should ensure her baby’s registration with a GP prior to discharge and they reminded her about this

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on each of the next three days. The CHFT IMR suggests that the baby’s eventual registration with a GP owed much to the perseverance of nursing staff. 15.9 Although the mother told hospital nursing staff on 12/4/08 that she did not need help in coping with her baby at home, the child’s premature birth meant that parenting would involve particular challenges. The child had chronic lung disease, which resulted in breathlessness during feeding. It was noted that the child was difficult to feed and slow to gain weight, and was an ‘irritable’ baby who did not settle easily. The child was prescribed medication for gastro-oesophageal reflux and constipation. Moreover, at this stage the child had been referred to Audiology services because the new-born hearing screening had raised questions about the baby’s ability to hear. 15.10 The chronology records that the NOR nurse contacted HV1 on 15/4/08 to request a joint pre-discharge visit to the family’s new home. As the mother and her child had moved out of HV1’s area, responsibility for the family passed at this time to the second health visitor (HV2). The child’s records were transferred to HV2’s area. 15.11 Following the child’s discharge home on 20/4/08 the NOR nurse visited the mother and her child at home on 21/4/08, 23/4/08 and 29/4/08. The child was gradually gaining weight and the NOR nurse did not document any concerns about the mother’s care of her baby. On 2/5/08 the NOR Nurse and HV2 made a joint home visit, when the chronology records that the mother was coping well, the child was taking feeds and the mother had support from her family who lived locally. Another pre-arranged joint visit on 8/5/08 failed to gain access to the house. Further home visits by the NOR nurse on 12/5/08, 16/5/08 and 27/5/08 documented a slow weight gain, and satisfaction that the mother was accurately administering her child’s medication following concern from the Consultant Paediatrician that she might be confused about this. HV2 made a home visit on 20/5/08 and had no concerns. On 30/5/08 HV2 made another home visit when the mother said she was having difficulty getting the baby to take full feeds. HV2 noted a cushion in the crib and that the baby was laying face-down. She advised the mother against these practices. HV2 arranged for a nursery nurse to visit to encourage the mother’s attendance at local support groups and Sure Start. Although not documented, HV2 told the KCHS IMR author that she was concerned about the child’s lack of stimulation. The NOR nurse visited on 2/6/08 and did not identify any concerns. On 3/6/08 the mother telephoned the NOR nurse for advice on weaning as she thought the baby was hungry. The NOR nurse indicated that the nursery nurse would provide advice about this. During her home visit on 4/6/08, the nursery nurse again noted a cushion in the crib and the baby being placed face-down, and advised against this. On the nursery nurse’s arrival at 1.00pm the mother had been in bed and the child had not been fed since about 8.00am. The nursery nurse provided advice on feeding, information on local groups and offered to walk with the mother to Sure Start sessions. The KCHS IMR notes that the mother is recorded as having strong views about the nursery nurse’s advice and although the nursery nurse planned to visit monthly there is no record of any subsequent visits. HV2 reported to the IMR author that she thought the mother had rejected further visits from the nursery nurse. 15.12 By this time the child had been home for just over six weeks and it was known that the child was profoundly deaf. The mother attended the Audiology clinic on

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24/4/08 where moulds were taken for the preparation of hearing aids and the ‘parents’ attended a further appointment on 8/5/08. The mother also attended an appointment with the Consultant Paediatrician on 8/5/08. The Advisory Teacher for the Hearing Impaired (AT1) from Kirklees Children’s Social Care, Children with Sensory Impairment Team made an initial home visit on 25/4/08 to provide information and support to the mother, but a second pre-arranged joint visit with the NOR nurse on 8/5/08 met with no access. It is clear that when the mother missed appointments with AT1, HV2 and the NOR nurse (see paragraph 15.11) on 8/5/08, this was because she was attending other appointments required to assess her child’s hearing, health and development. On 21/5/08 AT1 visited to provide further information and support relating to deafness and using sign language and on 22/5/08, the mother and child attended a Children’s Hearing Clinic appointment. The child’s hearing aids were fitted on 22/5/08 (chronology entry 23/5/08) and the nursery nurse, during her home visit on 4/6/08, had discussed the importance of ensuring the child wore the aids. 15.13 Thus far, this young mother had been available for all home visits (apart from 8/5/08) from HV2, the NOR nurse, the nursery nurse and AT1 and had attended all required outpatient Audiology/Hearing Clinic and paediatric appointments, although the chronology (7/5/08) notes that the child had been discharged from physiotherapy/occupational therapy because of a failure to attend appointments. Together with a recommended four-hourly feeding regime, an ‘irritable’ baby who was slow to gain weight and knowledge that her child was profoundly deaf, this must have been an extremely challenging time for the mother. 15.14 On 6/6/08 the Special Care Baby Unit (SCBU) at the mother’s local hospital left a message for the NOR team to say that the mother had been in contact the previous day and was concerned about the child’s feeding. SCBU staff had advised her to bring the baby into hospital (Ward 18) but she had not done so. Following contact with the Consultant Paediatrician, the NOR nurse visited and found that the baby had gained weight, although the mother maintained the baby had not been feeding well. When asked about weaning the mother said she had been advised to use baby rice but had not yet done so. The NOR nurse arranged for the baby to be reviewed overnight on Ward 18. Records indicate an agreement between the NOR nurse and staff on Ward 18 that if the mother failed to comply with this they would make a referral to Children’s Social Care because of a failure to follow medical advice. At the time the NOR nurse documented concerns about the mother’s care of her baby relating to ‘a poor understanding of the baby’s needs’ and a failure to follow written and verbal guidance about, for example, placing the child face-down in the cot with a cushion under the head. The mother took her baby to ward 18 and although initially resistant, she and the baby remained overnight. Ward staff were satisfied with the baby’s feeding and the NOR nurse planned to continue monitoring feeding and weight gain. The NOR nurse contacted HV2 with information about this incident. 15.15 ATI visited the mother and child at home on 10/6/08 and emphasised that the child should consistently wear the hearing aids. The NOR nurse also visited and did not record any concerns. Health visiting records (chronology entry 13/6/08) indicate that a housing support officer (from Kirklees Tenancy Support) had referred the mother to Home Start for individual support from a trained volunteer with parenting

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experience. The Home Start Co-ordinator reported to HV2 that the mother was reluctant to accept this service. A Home Start report prepared for the Overview Panel notes that a Home Start Co-ordinator had visited the mother at home on 12/6/08 but the mother was reluctant to accept help because numerous professionals were already involved. The mother indicated that she had no friends in the area, found it difficult to meet new people and was not receiving as much support from her extended family as she would have liked. Despite attempts to persuade the mother to accept support from Home Start, she declined this offer. 15.16 A joint visit by the NOR nurse and HV2 on 13/6/08 identified that the child was losing weight. The mother was given advice about feeding and reminded about removing the cushion from the crib and nursing the child face-up. The mother was advised not to add baby rice to the bottles but to feed this from a spoon, and was observed feeding the baby. A NOR home visit on 17/6/08, however, recorded a weight gain although the mother was only providing one rather than two rice feeds a day on the advice of her maternal relatives. The NOR nurse gave the mother further advice about feeding the baby. 15.17 A joint home visit by the NOR nurse and HV2 on 27/6/08 noted that although the child had gained weight since their last visit, the overall recorded weight was ‘falling off the centile chart’. The KCHS IMR, however, explains that as the child’s weight on hospital discharge had been on the lowest centile, only a small weight loss would have this effect. The mother reported during this visit that the child had been ill with diarrhoea and this is confirmed in the GP’s records (chronology entry 27/6/08). The NOR nurse and HV2 gave further advice about feeding and hygiene. It is noted that the mother had rejected the offer of support from Home Start. 15.18 On 2/7/08 the mother and baby attended a review out-patient appointment with the Consultant Paediatrician where the child’s height and weight were recorded. The chronology indicates that a letter was sent to the Audiology clinic requesting follow-up as the mother thought she had missed an appointment. The Consultant Paediatrician initiated further contact with the dietician regarding concern about the child’s growth and planned a subsequent review in two to three months. On 9/7/08 HV2 saw the mother and child at clinic and noted a ‘steady weight gain’. The child, however, was not wearing hearing aids and HV2 reminded the mother about the importance of this. 15.19 Following AT1’s home visit on 10/6/08, the mother had missed a subsequent visit on 26/6/08. However, she was at home for AT1’s next visit on 11/7/08 where the chronology notes that the child was not wearing hearing aids because, as the mother reported, they kept falling out. At this time the chronology (10/7/08) records that AT1 was in contact with Kirklees Early Years Service about funding for a nursery place. 15.20 On 18/7/08, following the NOR nurse’s liaison with the Consultant Paediatrician, it was decided to discharge the child from neonatal outreach with continuing care to be undertaken by HV2. The NOR nurse left a telephone message for HV2 of about this. The CHFT IMR notes that neonatal outreach was usually provided for a month following a child’s hospital discharge, but was extended in this case because of the child’s complicated healthcare needs. At the time, a transfer of

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care to the health visitor was accomplished by telephone contact, although the IMR notes that following a previous Kirklees Serious Case Review practice now requires information from neonatal outreach to be faxed to the health visitor and its receipt confirmed. 15.21 Home visits by HV2 on 25/7/08, 1/8/08 and 8/8/08 recorded HV2’s satisfaction with the child’s slow but steady weight gain. HV2 invited the mother to sign a referral to Sure Start, which she agreed to do. A Sure Start chronology entry (14/8/08) indicates that the referral was for support with attending hospital appointments and encouragement to interact with and provide stimulation for the child. The mother had discontinued the child’s medication and HV2 confirmed with the Consultant Paediatrician that this was acceptable if the child was feeding well and was free from vomiting. HV2 reminded the mother to lay the baby down on his/her back. HV2 also discussed the need for play and stimulation, which as the KCHS IMR comments had been concerning her for some time. 15.22 The mother and child attended their next appointment at the Children’s Hearing Clinic on 29/7/08, where the mother reported the child wore hearing aids during the day although they tended to fall out. She thought the child was more responsive when wearing hearing aids. Despite a reminder from HV2 during her visit on 8/8/08, the mother forgot a subsequent clinic appointment to collect the child’s new hearing aids. HV2 visited on 22/8/08 and agreed to make a further appointment for collection of the child’s hearing aids. At this home visit HV2 recorded that the child was more active and rolling from back to front. A Hearing Clinic recall appointment was made for 1/9/08 but subsequently re-arranged for 29/9/08. 15.23 AT1 made home visits on 5/8/08, 2/9/08 and 15/9/08. On the first visit she noted that the mother had lost one hearing aid. On the second visit AT1 was accompanied by a sign tutor and the mother agreed to start weekly sessions learning to use sign language. However, the chronology records a file note between 9/9/08 and December 2008 reporting that the sign tutor ‘often’ received no reply when visiting for weekly signing sessions. Later on 17/10/08, AT1 contacted HV2 to express her concern about the mother’s missed appointments with the sign tutor. 15.24 HV2 made further home visits on 5/9/08, 19/9/08 and 10/10/08. Over this period HV2 noted that the mother was coping well and the child was becoming more active and attempting to crawl. A chronology entry (5/9/08) makes it clear that HV2 knew the mother was receiving help from the Children with a Sensory Impairment Team and was learning sign language. Records from HV2’s visit on 19/9/08 note that the child was not wearing hearing aids and HV2 encouraged the mother to fit these. During her last visit during this period HV2 noted again that the child was not wearing hearing aids and gave further advice about their importance. Sure Start had informed HV2 that it could now offer a service and the mother accepted this offer. During a telephone conversation with the Sure Start Family Support Worker (FSW1) on 10/10/08, HV2 said that the mother would benefit from work relating to parenting, setting boundaries and routines. 15.25 The IMRs make numerous references to the mother and child missing appointments with Audiology, the Children’s Hearing Clinic and the Consultant Paediatrician. This caused significant professional concern for two reasons. First,

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the child’s premature birth meant that continuing paediatric monitoring was necessary to ensure the child’s healthy growth and development. Second, as the Advisory Teacher for the Hearing Impaired explained to the Overview Panel, young children with profound deafness require frequent monitoring and assessment by Audiology and the Children’s Hearing Clinic so that hearing aids can remain effective for a growing child. Otherwise, hearing aids become ill-fitting, fall out and may not be finely adjusted to meet the child’s hearing needs. Other out-patient appointments and home visits were all designed to support the child’s growth and development, to help the child learn communication skills and to support the mother in responding to her child’s needs. Missed appointments and unavailability for pre-arranged home visits are recorded here because of their significance in relation to the child’s current and future wellbeing, professional concern and, as will become evident, an emerging pattern of parental ambivalence/resistance to professional intervention. The Overview Panel, however, thought it was necessary to evaluate the significance of missed appointments in the context of the mother’s overall attendance record and detailed information for the Review period is included at the end of this overview report. Over the relatively short period between early September and early October 2008, the chronology records the following missed appointments: Mother was ‘often’ not replying when sign tutor visited for arranged weekly

sessions Mother and child had not attended an appointment with the paediatric

dietician following referral from the Consultant Paediatrician (chronology entry 9/9/08)

Mother told HV2 she had forgotten an appointment at the Child Development Centre (chronology entry 19/9/08) but had actually missed two appointments for a Schedule of Growing Skills assessment at the Centre (chronology entry 10/10/08)

Mother did not attend Children’s Hearing Clinic appointment on 29/9/08 Mother and the child did not attend a review appointment with the Consultant

Paediatrician on 8/10/08 15.26 HV2 and FSW1 from Sure Start made a joint home visit on 24/10/08. HV2’s records indicate that the child was not wearing hearing aids and the mother said they kept falling out. The chronology (24/10/08) suggests some confusion here as it notes HV2 reminding the mother about an appointment at the Child Development Centre on 29/10/08 while an earlier chronology entry (10/10/08) indicates the withdrawal of this service because the mother had already missed two appointments. There are no further records for HV2 and the health visiting service did not resume contact with the family until February 2009 when HV3 assumed responsibility for the case. 15.27 Between 24/10/08 and 11/11/08 the chronology contains numerous references to work undertaken by staff from the Sure Start Children’s Centre (hereafter referred to as the Children’s Centre). The Children’s Centre records note the joint visit of FSW1 and HV2 at mid-day on 24/10/08 (see paragraph 15.26). The Children’s Centre chronology and the Directorate of Children and Young People IMR narrative record that FSW1 and HV2 found the mother in bed and the house untidy and dirty. They also noted that the child was unclean. The mother’s lifestyle involved staying awake at night and sleeping during the day. Records indicate the child was not

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wearing hearing aids. It is noteworthy that HV2’s records of this visit omit any reference to the mother being in bed or to the house and child being unclean (see chronology entry for 24/10/08). 15.28 On 4/11/08 FSW1 emailed Children’s Social Care requesting information about the family. This was in response to HV2 telling FSW1 that she had previously made a referral to Children’s Social Care but nothing had been done. Children’s Social Care - Children with a Disability Unit replied on 5/11/08 and conveyed information about four referrals concerning the mother’s ‘behaviour problems’ in 2003. They had no current involvement with the family and there was no record of any previous referral from HV2. This is rather perplexing. However, the KCHS IMR refers to later records made by HV3 explaining that HV2 had raised the possibility of referring the child to Children’s Social Care (around October 2008) as being a child ‘in need’ under s.17 of the Children Act 1989 because of missed healthcare appointments and inadequate use of hearing aids. The mother had subsequently refused to work with HV2. This was confirmed by HV2 when interviewed by the IMR author but was not recorded by her at the time. The only explanation for FSW1’s impression that HV2 had referred the family to Children’s Social Care must relate to later information that HV2 had considered this or possibly threatened to do so. 15.29 On 4/11/08 FSW1 made a home visit with her manager to explain the Children’s Centre involvement. They identified the need for a fire guard and safety gate and agreed with the mother that a Community Link Worker (CLW1) would support her in attending activities at the Children’s Centre. The mother missed FSW1 and CLW1’s pre-arranged home visit on 10/11/08 and said during later telephone contact that she had forgotten. However, the chronology, although not the IMR narrative, records that she was available for their home visit on 11/11/08. Children’s Centre records note that the mother brought her child to social events at the Children’s Centre on 22/11/08 and 25/11/08. However, subsequently CLW1 was unable to get any response when she telephoned the mother on 7/12/08, 8/12/08, 15/12/08 and 23/12/08 and thus could not provide the mother with any support for the remainder of 2008. 15.30 AT1’s last successful visit had been on 15/9/08 (see paragraph 15.23). A chronology entry for 25/10/08 to 11/12/08 notes that in this intervening period AT1 had frequently tried to contact the mother by phone to arrange an appointment but with no success. Although the mother had, by now, missed three appointments at the Child Development Centre AT1 demonstrated good practice by requesting the Centre to send a further appointment. LT1 managed to complete a home visit on 6/11/08 when the records note that the child was not wearing hearing aids. AT1 referred the child to the speech and language therapy service (SALT) because of developmental delay in this area. A joint visit between SALT and AT1 on 17/11/08 resulted in no access. The CHFT IMR notes that AT1 informed SALT about the mother’s history of failing to attend pre-arranged appointments. On 16/12/08 AT1 and the sign tutor made a home visit where it was noted the child’s hearing aids were much too small and had not been worn for several weeks. The child’s vocalisations were limited. It is unsurprising that the child’s hearing aids were too small as the mother had last attended an appointment at the Children’s Hearing Clinic on 1/9/08 and had missed two subsequent appointments on 29/9/08 and 26/11/08.

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15.31 On 19/11/08 the mother and child failed to attend their next appointment with the Consultant Paediatrician. This was the second consecutive appointment they had missed. The mother missed an appointment at the Children’s Hearing Clinic on 26/11/08 - the second consecutive appointment with non-attendance. AT1’s contact with the Child Development Centre on 9/12/08 revealed that the mother had failed to attend an appointment sent at AT1’s request (see paragraph 15.30) and this service would not send further appointments. This was the fourth appointment that the mother had missed at the Child Development Centre and as far as I can see from the chronology she never accessed this service. A further review appointment with the Consultant Paediatrician was missed on 31/12/08 – the third consecutive appointment. 15.32 Professionals had become increasingly concerned about this mother’s unwillingness or inability to attend healthcare appointments and her unavailability for pre-arranged home visits (see paragraph 15.25 and inclusion of detailed information about the mother’s attendance record at the end of this report). From mid-October to the end of December 2008 the mother missed the following appointments and professional contacts: A pre-arranged joint home visit by FSW1 and CLW1 on 10/11/08 Inability of CLW1 to contact the mother by phone between 7/12/08 and

23/12/08 Inability of AT1 to contact the mother by phone between 25/10/08 and

11/12/08 A pre-arranged visit by AT1 and SALT on 17/11/08 Missed appointments with the Consultant Paediatrician on 19/11/08 and

31/12/08 – now amounting to three consecutive missed appointments Missed appointment at the Children’s Hearing Clinic on 26/11/08 – now

amounting to two consecutive missed appointments Information that the mother and child had missed three appointments at the

Children’s Development Centre and subsequently missed a further appointment arranged at the request of AT1.

15.33 The mother visited her GP appropriately during this year for the child’s repeat prescriptions and when the child was ill. Additionally, the GP Practice received letters about the child’s hospital admissions and discharges and subsequent healthcare arrangements. Some of these were copies of letters to other professionals for the GP’s information and some constituted direct correspondence with the Practice. On 7/5/08 the GP received a letter from the Children’s Physiotherapy/Occupational Therapy Service to say the mother had been discharged because of a failure to keep appointments. The GP received a letter from the Consultant Paediatrician on 9/5/08 reporting on the child’s medication, progress and significant hearing impairment and on 29/5/08 a letter from the Associate Specialist in Community Paediatrics with responsibility for children’s Audiology services with information about the child’s hearing impairment and intervention by AT1. The letter from the Associate Specialist in Community Paediatrics noted that the child had two paternal relatives who had a hearing impairment. However, it did not provide any further information about the identity of these relatives and the father’s family remained relatively invisible. On 2/7/08 the

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chronology records the GP’s receipt of another letter from the Consultant Paediatrician noting the child’s revised medication and commenting on the child’s development. The chronology indicates that the GP was regularly informed about the child’s attendance at the Children’s Hearing Clinic and the mother’s management of her child’s profound deafness. 15.34 The chronology indicates that a further letter from the Consultant Paediatrician was received by the GP on 28/11/08 with information about the mother and child’s two missed appointments. The KCHS IMR provides more detailed information, noting this was a copy of a letter sent to the ‘parents’ emphasising the importance of keeping appointments and providing a date for another appointment. The IMR narrative notes that the GP reacted to this letter by trying unsuccessfully to contact the mother by telephone. The GP subsequently sent a letter advising the mother of the Consultant Paediatrician’s communication, the date of the next appointment and requesting a current telephone contact number. 15.35 When West Yorkshire Police interviewed the mother’s former partner following the child’s hospital admission in November 2010, he reported that he had maintained a relationship with the child’s mother for about six years. Their relationship had concluded in January 2010. For the first year of the child’s life he saw the mother and child every day but the relationship deteriorated when the child was about a year old and the mother began a relationship with another man. This does not accord with the mother’s account when she told HV1 on 7/1/08 that she was no longer in a relationship with the child’s father. Nevertheless, if the former partner’s account is accurate he would have been in close contact with the mother during 2008, although none of the professionals visiting the home were aware of his existence. The only clue to his (or another man’s) involvement with the mother comes from numerous chronological entries during early 2008 about ‘parents’ visiting the child on the Special Care Baby Unit. On 9/5/08 the GP received a letter from the Consultant Paediatrician noting that ‘Mum and Dad’ were happy with the child. 15.36 During most of 2008, the IMR narratives and chronologies record a young single mother who managed to cope, for the most part, with a premature baby who had significant healthcare needs and profound deafness. Apart from the child’s weight loss recorded on 13/6/08 when the mother was adding baby rice to the child’s bottle, records indicate a slow but steady weight gain which is not unexpected in premature babies. However, the records document continuing reminders from HV2 and the NOR nurse about removing the cushion from the baby’s crib and laying the child face-up. HV2 also told the KCHS IMR author that she was worried about the mother’s willingness and ability to provide her child with adequate stimulation and interaction, although she did not record these concerns. The chronology also records numerous professional visits where it was noted that the child was not wearing hearing aids. The mother managed to juggle the demands of attending numerous out-patient appointments and being available for professionals’ home visits until around August/September 2008 after which records indicate a pattern of non-attendance at community healthcare appointments and unavailability for home visits. 16.0

Analysis of Year 2: January 2008 to end of December 2008

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16.1 OFSTED’s and other national evaluations of Serious Case Reviews have commented on the lack of a child-centred focus in professional practice and in Serious Case Reviews (Brandon et al 2009; Rose and Barnes 2008; OFSTED 2008; 2009; 2011) Although this child was too young to express his/her feelings and experience of family life we know that HV2 was worried about the mother’s ability to provide the child with appropriate interaction and stimulation. Professionals frequently recorded that the child was not wearing hearing aids and this must have had an impact on the child’s language development and ability to make his/her needs known. Similarly, the mother was not routinely available for weekly sessions with the sign tutor and this impeded her ability to develop tools for non-verbal communication. During this year, however, HV2’s records indicate satisfaction with the child’s social and emotional development and the Consultant Paediatrician’s letter to the GP (chronology entry 2/7/08) notes that the child was ‘developmentally very vocal, chuckles, alert and responsive’. At this stage the records point to a generally happy child who was becoming increasingly active and mobile. However, learning and health care professionals were concerned that the later effects of inadequate social interaction, a lack of appropriate stimulation and an inability to communicate would have diminished this child’s ability to achieve the five outcomes in Every Child Matters (Chief Secretary to the Treasury 2003). (See also paragraph 8.2.2 for a discussion of potential outcomes associated with profound deafness).There is evidence that professionals concentrated on the child’s wellbeing, provided services in a timely fashion, made every effort to enhance the child’s developmental opportunities and tried to help the mother understand and respond to her child’s additional needs. 16.2 There is evidence throughout the IMR narratives and chronologies of good inter-agency/professional communication and joint working particularly between HV2 and the NOR nurse. There was also appropriate communication between HV2, the NOR nurse, the Hospital Special Care Baby Unit and community health and Audiology services. AT1 also kept the health visitor informed about concerns regarding the mother’s unavailability for appointments. 16.3 The KCHS IMR is critical of an absence of any communication between the GP and the health visitor. A hospital discharge letter was received by the GP on 21/4/08, which in addition to providing details of the child’s complex medical history and medication, commented that this was a ‘single, first time Mum without much home support’ and referred to the family’s recent re-housing. The IMR author suggests that this should have prompted the GP to initiate discussions with HV2. Ongoing contact between the GP and HV2 would have enabled the GP to maintain current knowledge about the family’s circumstances. However, as the IMR author acknowledges the GP was aware that the health visitor and NOR team would be supporting and advising the mother and that the Consultant Paediatrician would arrange out-patient care. Letters from the Consultant Paediatrician (9/5/08 and 2/7/08) did not raise any safeguarding concerns and reported that the child was developing well. As has been noted those health and social care professionals most closely involved with the child’s welfare maintained regular communication and the Overview Panel considered that, in this case, communication from the GP would not have served a clear purpose in the child’s best interests.

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16.4 Additionally, none of the professionals involved in the child’s care, including HV2, attempted to involve the GP in any discussion about this family. Direct communication between the GP and other professionals would have ensured that they all had access to full information about this child and family’s needs. On interview by the IMR author, the health visitors said they thought it was unnecessary to contact the GP given continuing oversight from the Consultant Paediatrician and the Associate Specialist in Paediatrics with responsibility for Audiology. The Overview Panel considered that these presumptions about the division of professional responsibility were reasonable in the circumstances of this case. 16.5 Both the CHFT and KCHS IMRs recognise good inter-agency/professional communication but comment on an absence of multi-agency/professional communication and intervention. The CHFT IMR notes that there was no formal discharge planning meeting prior to the child’s return home from hospital in April 2008, which would have provided an opportunity for professionals to share information and ensure co-ordination of their roles. The IMR author comments that this may have served to identify the need for a CAF assessment at an early stage. At the time the Neonatal Outreach (NOR) nurse held responsibility for the timing and arrangement of discharge meetings and these were matters governed by discretion rather than formal guidance. The CHFT IMR includes a recommendation to formalise guidance in this context to ensure that discharge planning meetings are arranged under appropriate circumstances. 16.6 The CHFT IMR comments that professionals should have recognised the need for a CAF assessment following the child’s discharge from hospital. Additionally later in 2008 when professionals became aware that the mother was missing a significant number of healthcare and Audiology appointments and was often unavailable for home visits, the IMR suggests that someone should have taken responsibility for convening a multi-agency meeting. This would have enabled professionals to construct an overall picture of the mother’s non-attendance and to have considered strategies for responding to this problem. Multi-agency meetings would, of course, have been integral to CAF working but in the absence of a CAF assessment, individual professionals should have been alert to the potential benefits of multi-agency collaboration. It is difficult to understand why professionals clearly recognised the importance of inter-agency/professional communication but did not extend this thinking to multi-agency arrangements. 16.7 The KCHS IMR notes the Community Midwife’s referral to the health visiting service did not indicate any maternal vulnerability but that already known factors such as the mother’s single status and relatively young age should have indicated completion of a pre-CAF checklist. When HV1 administered the Universal Needs Assessment (UNA) checklist on her first visit to the mother she identified the mother’s poor school attendance record and her distrust of people. However, the KCHS IMR comments that HV1 knew enough about the mother’s circumstances and the child’s complex health needs to indicate the relevance of a pre-CAF checklist at this early stage. The IMR further notes that a CAF assessment and associated multi-agency meetings were clearly required from around the end of May 2008 when HV2 became concerned about the child suffering from a lack of social interaction and stimulation. At that time the CAF was not embedded in practice and its relevance for working with this family was evidently not at the forefront of professionals’ minds.

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This is unfortunate as the child clearly had additional needs which were relevant for achieving the five outcomes in Every Child Matters. Numerous professionals and services were involved with this family without the foundation of multi-agency collaboration that would have been afforded through CAF arrangements. A CAF assessment should have provided some clarity about planning such that professionals and the mother could jointly identify the outcomes they were seeking to achieve and their respective roles in this context. 16.8 The UNA checklist used by HV1 was subsequently replaced by an electronic UNA in health visitors’ records providing prompts that encourage health visitors to explore any indications of problematic maternal history. This form of the UNA incorporates a pre-CAF checklist. The KCHS IMR also notes that by late 2011 a pre-CAF checklist will be incorporated into all midwifery booking visits across Kirklees, thus establishing the CAF as the common form of early assessment used by community midwives and health visitors. 16.9 The KCHS IMR notes that GP records provided a ‘legible, clear chronology’ of the health services provided for the family throughout the period covered by this Serious Case Review. However, on at least two occasions (27/6/08 and 8/10/08) the chronology suggests the GP did not record who had brought the child to the surgery for treatment. The IMR includes a recommendation to ensure that GPs record who is present and their relationship to the child during any consultation with a child or young person. Health visiting records were, however, of variable quality, not always made contemporaneously and sometimes lacking sufficient detail. Some issues were not recorded, for example the health visitor’s concern about the child lacking appropriate stimulation and the mother’s rejection of further contact when HV2 considered making a referral to Children’s Social Care in October 2008. The IMR author indicates that these issues have largely been addressed through the introduction of an electronic health recording system and that previously inadequate recording did not affect the quality of services provided to the mother and child. 16.10 The CHFT and KCHS IMRs include numerous chronological entries, largely from the NOR nurse and HV2, about the child’s slow weight gain and advice given to the mother about feeding and weaning. This could give an impression that professional concern about the child’s weight reflected the mother’s inability to provide adequate care. The chronology entry (6/6/08) which records agreement between the NOR nurse and hospital staff about a referral to Children’s Social Care if the mother failed to take her child to Ward 18 for review may amplify this impression. However, for the most part the chronology records slow but steady weight gain and it is only on one occasion (13/6/08) that records indicate a weight loss when the mother was adding baby rice to the bottle. The mother appropriately asked for advice about feeding and weaning and it was her initiative in contacting the Special Care Baby Unit at her local hospital that led the NOR nurse to arrange a review on Ward 18. The Overview Panel sought clarification about how it should interpret the IMRs’ focus on the child’s weight and concluded that while the mother was clearly anxious about this, feeding difficulties and slow weight gain are not unusual in very premature babies. This did not reflect on the mother’s capacity to care for her child.

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16.11 The CHFT IMR notes that although staff from Sheffield Children’s Hospital informed the Community Midwife and HV1 about the mother’s ongoing need for re-housing, this was not addressed until the mother expressed her concern to staff at her local hospital’s Special Care Baby Unit around 3/3/08. The staff immediately contacted Kirklees Housing with the mother’s agreement. Kirklees Accessible Homes Team responded promptly with a home visit to the mother on 27/3/08 and contact with the Special Care Baby Unit on 31/3/08 to clarify the child’s needs. The mother started her tenancy for a suitable house on 7/4/08. 17.0

Descriptive account of Year 3: January 2009 to end of December 2009

17.1 CLW1 from the Children’s Centre made a home visit on 7/1/09 when it is recorded that an unknown man answered the door. The mother said she did not want any further help from the Children’s Centre and the case was subsequently closed on 8/1/09. On the 22/1/09 FSW2 informed HV2 of the case closure. HV2 requested that the case should be kept open for the moment as she had concerns about the family and was due to discuss these during supervision with her manager. Although this appears to have been a conversation between Children’s Centre staff and HV2, there are no records from HV2 following her last home visit on 24/10/08 after which the mother refused to have further contact with her. The Children’s Centre FSW2 met with HV3 on 10/2/09. HV3 attempted to persuade the Centre to maintain the family as an open case, but the records indicate final closure on 10/2/09. 17.2 AT1 made successful home visits on 8/1/09, 30/1/09, 26/2/09 and 12/3/09, but on 26/3/09 the mother was out when ATI called for a pre-arranged visit. During the visit on 26/2/09, AT1 noted the child to have generally good non-verbal skills but few vocalisations. The mother was available for home visits by the signing tutor on 22/1/09, 29/1/09, 12/2/09 and 1/4/09. A long gap between the last two visits is not explained in the records. 17.3 The mother attended a Children’s Hearing Clinic appointment on 19/1/09.This followed two consecutive missed appointments in late 2008 and the child had not been seen at the Clinic for over four months. Records of this appointment indicate that the mother was experiencing difficulty getting the child to wear hearing aids and the child kept pulling them out. The mother had misplaced the aids and moulds were taken for new ones. Although the option of a cochlear implant had been discussed with the mother, she did not want a referral to the cochlear implant team at this stage. The Associate Specialist in Paediatrics emphasised the importance of establishing consistent hearing aid use to help the child’s social development and communication skills. On 2/3/09 the mother attended an appointment with the Audiologist where the child had new hearing aids fitted and she attended a follow-up appointment at the Children’s Hearing Clinic on 1/4/09. On 1/4/09 the mother reported that the child responded better when using hearing aids but frequently pulled them out. 17.4 The GP received direct correspondence from the Consultant Paediatrician on 13/1/09 with information that the mother and child had by then missed three consecutive appointments and an appointment at the Child Development Centre for assessment. The GP was requested to encourage the mother’s attendance at

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appointments. In response the GP attempted unsuccessfully to contact the mother by telephone and for the first time tried to contact the health visitor with two unsuccessful telephone calls. There is no indication of any further attempts or evidence that the GP left messages for the health visitor. The IMR records the GP’s handwritten note of an appointment made at the surgery for 28/1/09, which was not attended by the mother or child. Records suggest that the GP took no further action to contact the mother or health visitor. On 30/1/09 the GP received a letter from the Associate Specialist in Paediatrics (copied to the health visitor), which reported on the child’s profound hearing loss and discussions with the mother at the Clinic appointment on 19/1/09. This was followed by a letter from the Audiologist on 7/4/09 reporting on the mother’s attendance on 2/3/09 and the option of cochlear implants for the child. 17.5 A chronology entry on 9/2/09 indicates that HV3 had now assumed responsibility for the family. Following contact from the Audiology service, HV3 made an opportunistic home visit on 10/2/09 with the purpose of reminding the mother about the next Children’s Hearing Clinic appointment and discussing the importance of the child using hearing aids. The mother said she had not received any correspondence about appointments. She felt under pressure to allow a cochlear implant but was not yet mentally ready to accept this for her child. Difficulties persisted with consistent hearing aid use with the mother reporting that the child had some hearing and she was therefore reluctant to fit the aids and that in any event the child continued to remove them. HV3’s records refer to the child eating well, vocalising, smiling, crawling and pulling to a standing position with support. HV3 later phoned the mother to inform her of the appointment date at the Children’s Hearing Clinic on 1/4/09. As is noted above, the mother subsequently attended this appointment. 17.6 The chronology notes a written (undated) report to the GP in April 2009 regarding an assessment by SALT. This records the child as being interactive and friendly. The child was very active during the assessment but had a limited attention span. Sign language had been introduced to be used alongside speech. The assessment concluded that the child and mother required further intervention with regard to the child’s delayed language skills and the development of appropriate play skills. 17.7 The chronology records further successful home visits by the sign tutor on 18/4/09, 30/4/09, 7/5/09 and 14/5/09. The sign tutor visited on 16/5/09 but there was no reply. A chronology entry dated 20/4/09 refers to a successful home visit by a member of the Children with Sensory Impairment Team but does not include their identity. AT1 made a pre-arranged visit on 6/5/09 but could not gain access. This visit was re-arranged for 20/5/09 but was cancelled by the mother. Chronological entries do not identify a further home visit until 20/7/09 when AT1 visited with SALT. The IMR narrative, however, notes that the mother had cancelled four previous appointments for AT1 to visit. AT1 is recorded as contacting Kirklees Early Years Service about a nursery placement for the child at this time. 17.8 The mother missed a fourth consecutive appointment with the Consultant Paediatrician on 6/5/09. This led the Consultant Paediatrician to contact the Named Nurse for Safeguarding Children in accordance with Calderdale and Huddersfield

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NHS Foundation Trust’s paediatric non-attendance policy (chronological entry 8/5/09). The Named Nurse subsequently contacted HV3 who reported there were no additional concerns about the family. HV3 had discussed non-attendance at appointments with the mother who had said her boyfriend had a car and attendance was not a problem. It was agreed that HV3 should contact the mother to remind her about the next appointment with the Consultant Paediatrician arranged for 9/9/09. AT1 was also contacted by the Named Nurse and reported on involvement by the Children with Sensory Impairment Team. In subsequent discussions the Named Nurse and Consultant Paediatrician agreed to take no further action but noted that the mother’s attendance at the next appointment on 9/9/09 was imperative. 17. 9 HV3 made a successful home visit on 27/5/09. Records of this visit note that the child showed a good weight gain. The child was very active and walking, but was clumsy. HV3 noted that the house was clean, toys were available and the child was vocalising. However, the child was not wearing hearing aids. When HV3 discussed problems about non-attendance at appointments the mother said she got mixed up and confused about them. However, the records suggest the mother rebuffed HV3’s suggestions about potential solutions to this problem. Although HV3 thought a further referral to the Children’s Centre might be helpful to encourage the child’s interaction with other children, the mother was reportedly reluctant to accept this. The mother expressed a preference for a pre-school nursery placement. HV3 noted the child’s physical and social development as being age appropriate. 17.10 Significantly the mother reported to HV3 on 27/5/09 that she had a boyfriend but would not disclose his name or any other details. HV3 did not see anything in the house suggesting a male presence. This is unlikely to have been the mother’s former partner as he reported that their relationship, while not finishing until January 2010, had deteriorated about a year after the child’s birth when the mother met a new partner. It is also unknown whether this ‘boyfriend’ was the same man that had opened the door to CLW1 on 7/1/09. HV3’s records for 27/5/09 refer to her perception that the mother was a ’very private person’. 17.11 HV3’s next opportunistic home visit was on 27/7/09 when it is recorded that the child was again not wearing hearing aids because his mother said they were too small. The mother told HV3 the child could hear and could say Mum and Dad in Asian language. This begs the question of how far the mother’s former partner, who is of Pakistani origin, was still involved with the family. It is possible that he was still involved to some extent since he told West Yorkshire Police their relationship did not come to a complete end until January 2010. There is no evidence that HV3 explored the mother’s comments about this any further. HV3 recorded that the child could walk but was very unsteady. There is an indication in HV3’s records that the mother did not place appropriate boundaries on the child’s behaviour. The IMR narrative provides further details about the mother’s expressed willingness for her child to be referred for consideration of a cochlear implant and her agreement about referral to the Sure Start Children’s Centre so that her child could have opportunities to socialise with other children. HV3 informed AT1 that the mother was now willing to consider a cochlear implant. 17.12 Continuing pre-arranged home visits by the sign tutor met with no response on 4/6/09 but a successful visit on 18/6/09. The sign tutor could not gain access at a

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visit on 2/7/09 and the next chronological entry regarding a visit by the sign tutor is on 24/9/09 when a joint visit was accomplished with AT1. Following AT1’s last home visit on 20/7/09, the mother missed a further visit from AT1 on 3/8/09. AT1 tried unsuccessfully to contact the mother on 21/8/09 and 24/8/09 to arrange a further appointment. The chronology indicates that AT1 was unable to arrange an appointment until 3/9/09, but the mother was apparently not at home when AT1 visited. In September 2009 AT1 was liaising with Sure Start about services for the mother and child although the chronology is unclear about whether this was for a pre-school nursery placement. However, a conversation on 27/7/09 between HV3 and the Children with Sensory Impairment Team indicates that AT1 was attempting to locate funding for a pre-school nursery place. AT1 managed a successful home visit on 4/9/09 when the chronology indicates that Sure Start/Children’s Centre forms were completed. The mother told AT1 that she was finding it hard to look after her child (who was by this time about twenty-one months old) because of communication difficulties. 17. 13 The mother missed her next and fifth consecutive appointment with the Consultant Paediatrician which was due on 9/9/09. As a consequence the Consultant Paediatrician informed the GP and Associate Specialist in Paediatrics in writing that no further appointments would be offered but the case would be left open if there were any concerns. In the letter to the GP the Consultant paediatrician raised the possibility of social issues as affecting the mother’s ability to keep appointments. 17.14 AT1 was due to make home visits on 16/9/09 when the mother was not at home and on 1/10/09 when the appointment was cancelled. However, AT1 and the sign tutor made a successful joint visit on 24/9/09 but noted that the child was again not wearing hearing aids. The Children’s Centre chronology (24/9/09) records AT1’s contact requesting help with re-housing and allocating a nursery place. A further appointment with AT1 on 1/10/09 was cancelled. AT1 accomplished a home visit on 6/10/09 when results of the cochlear implant assessment were discussed (the ‘parents’ and child had attended for this assessment on 16/9/09 when it was concluded that at the time a cochlear implant was inappropriate due to the child’s hearing capacity but further assessment would be necessary). The chronology notes that AT1 started the CAF assessment during the visit on 6/10/09. Despite a promising start to the CAF assessment the mother was unavailable for AT1’s home visits on 17/10/09 and 19/10/09. The chronology notes that AT1 subsequently tried to contact the mother on numerous occasions without success. AT1 was next able to accomplish a home visit on 16/11/09 with the Children’s Centre family support worker (FSW3), when working under the CAF was discussed. A chronology entry for 6/11/09 queries why the mother has not attended an Audiology appointment but I cannot find any other chronological entries that identify the date of this appointment. The mother had last been available for the sign tutor’s visit on 24/9/09 and the chronology indicates that the sign tutor’s next visit was on 15/10/09. Following this the sign tutor made a joint visit with AT1 on 14/12/09 but no-one was in the house. The chronology does not record any successful visits by the sign tutor for the remainder of this year. 17.15 HV3 made her next opportunistic home visit on 13/11/09 as the mother had not responded to telephone calls. Although HV3 recorded a light on in the house,

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she could not achieve any reply. HV3 left a card with an appointment for 20/11/09. When HV3 visited on 20/11/09 she could not gain any response. On 4/12/09 HV3 received a copy of the CAF assessment completed by AT1. The CAF form recorded that the reasons for the assessment were ‘to determine what support/additional services might be required to support [the child] and family in facilitating the best circumstances for [the child’s] development’. 17.16 The chronology records a home visit on 16/11/09 by FSW3 from the Children’s Centre but notes there was no clear record of what happened during this visit. Continuing efforts to achieve funding for a pre-school nursery place are recorded on 7/12/09. On 9/12/09 the chronology records AT1’s difficulties in contacting the mother and it was agreed between FSW3 and the Children’s Centre manager that a letter should be sent to the mother stating that if she did not contact FSW3 within ten days the case would be closed. 17.17 The chronology records that the Associate Specialist in Paediatrics received a letter from the cochlear implant service on 14/12/09 noting concern about the child’s inconsistent use of hearing aids. The letter indicated that the ‘parents’ were keen to continue the assessment process and agreed to ensure the child wore hearing aids. 17.18 During this year the GP received letters from the Consultant Paediatrician about the mother’s non-attendance at appointments and from the Associate Specialist in Paediatrics regarding the child’s profound deafness (30/1/09, 7/4/09, 26/8/09 and 21/12/09) and related interventions. Records indicate the mother consulted her GP appropriately when the child was ill and that the child’s immunisations were up to date. 17.19 Professionals remained concerned about the mother’s failure to attend appointments and to be available for home visits (see paragraph 15.25 and detailed account of the mother’s attendance record at the end of this report). Over the course of the year the mother missed visits/appointments as follows: 26/3/09: home visit by AT1 6/5/09: Out-patient appointment with Consultant Paediatrician (the fourth

consecutive appointment which the mother had failed to attend) 6/5/09: home visit by AT1 (by 6/7/09, it was noted that the mother had

cancelled four previously arranged visits by AT1) 16/5/09: home visit by sign tutor 21/5/09: home visit by AT1 4/6/09: home visit by sign tutor 2/7/09: home visit by sign tutor 3/8/09: home visit by AT1 3/9/09: home visit by AT1 9/9/09: Out-patient appointment with Consultant Paediatrician (the fifth

consecutive appointment which the mother had failed to attend) 16/9/09: home visit by AT1 17/10/09: home visit by AT1 19/10/09: home visit by AT1 (the chronology notes AT1’s numerous

unsuccessful attempts to contact the mother by phone) 20/11/09: home visit by HV3

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14/12/09: joint home visit by AT1 and sign tutor 17.20 Following completion of the CAF assessment by AT1 and the mother in November 2009, the first multi-agency CAF meeting was held on 7/12/09. The minutes identify attendance by AT1, ‘Up and Working’ and Kirklees Neighbourhood Housing and apologies from HV3. Although not listed as attending, the mother was clearly there and contributed to the discussion. The CAF assessment had identified the need for change in the following areas:

• The mother should receive further advice, guidance and support in ‘creating a home environment supportive of [the child’s] needs’.

• The child would benefit from day care to compensate for delayed development of language/communication and play skills associated with inconsistent hearing aid use and limited opportunities for social interaction with other children. This would also enable the mother to access training and/or employment.

• Re-housing to provide a safe and secure outdoor play area for the child. The assessment described the mother as a ‘caring and loving parent’ who provided the child with a stable family life and gave the child appropriate encouragement and praise, although she did not always impose consistent boundaries on the child’s behaviour. 17.21 The meeting on 7/12/09 discussed these issues, including the mother’s wish to take a British Sign Language course. Minutes included action by the Children’s Centre to secure funding for a pre-school nursery place, a home visit by Kirklees Neighbourhood Housing to assess the garden and arrange the mother’s inclusion on the housing exchange register and investigations by ‘Up and Working’ to identify appropriate training opportunities. 17.22 By the end of this year the child was identified as having delayed language development and communication and play skills associated with the lack of consistent hearing aid use and insufficient opportunities to learn and practice non-verbal communication through signing. The child’s capacity to develop appropriate play and social skills was limited by a lack of interaction with other children. The CAF assessment notes that the child’s underdeveloped communication skills sometimes led the child to be frustrated about an inability to convey his/her needs or to understand parental boundary setting. Nevertheless, the records indicate that the child’s development was otherwise satisfactory and chronological entries suggest a happy and friendly child who had a warm relationship with the mother. There is nothing to suggest at this stage that the child’s experience of family life and relationships was significantly problematic. However, the Overview Panel remained alert to potential difficulties in the absence of opportunities for the child to learn and practise effective communication skills and of attention to the child’s socio-emotional development as a profoundly deaf child in a hearing community (see also comments at paragraph 8.2.2). 18.0

Analysis of Year 3: January 2009 to end of December 2009

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18.1 The CHFT IMR notes that when the mother missed her fourth consecutive appointment with the Consultant Paediatrician on 6/5/09 the Consultant appropriately contacted the Hospital Trust’s Named Safeguarding Nurse in accordance with the paediatric non-attendance policy. However, although the Named Nurse subsequently sought information from HV3 and AT1 about the child’s wellbeing and reasons for non-attendance at appointments, she did not contact Children’s Social Care to enquire about any information they might have. Although the Consultant Paediatrician was concerned about the mother and child’s non-attendance, a further appointment was not provided until 9/9/09 – four months later. 18.2 The mother missed the appointment on 9/9/09 and the CHFT IMR suggests that at this point the Consultant Paediatrician should have made a referral to Children’s Social Care since continuing paediatric monitoring and assessment are important for ensuring a premature baby’s healthy development. Similarly, it would have been good practice to re-new contact with the Trust’s Named Safeguarding Nurse. In the event the Consultant Paediatrician wrote to the GP and Associate Specialist in Paediatrics noting that no further appointments would be offered but suggesting a review if there were any concerns. There is no evidence that HV3 was informed about this decision. It is perhaps surprising that given concern about the mother’s failure to consistently attend appointments and five missed appointments with the Consultant Paediatrician, there is no evidence of heightened professional attention to potential safeguarding issues. In this context national evaluations of Serious Case Reviews have found that a persistent failure to attend appointments and to avoid contact with professionals tends to characterise neglectful parenting (Brandon et al 2008; 2009). 18.3 The CHFT IMR comments that in 2009 the Trust’s paediatric non-attendance policy had only recently been introduced. At the time of completing the IMR an audit of the policy had been undertaken by the designated Doctor for Safeguarding Children and the Paediatric Liaison Sister. The IMR notes that the results of this audit will enable an evaluation of the policy’s effectiveness and indicate any necessary changes. 18.4 The KCHS IMR is critical that the GP did not adopt a more proactive role in communicating with other professionals, particularly HV3, and discussing the child’s deafness and non-attendance with the mother during consultations. Following the Consultant Paediatrician’s letter dated 13/1/09 requesting the GP to encourage the mother’s attendance at appointments, the GP tried unsuccessfully to contact the mother once and HV3 twice. The GP then sent the mother an appointment to attend the surgery on 28/1/09. When she missed this appointment, the GP took no further action. The IMR similarly notes that when the Consultant Paediatrician wrote to the GP on 24/9/09 stating that no further appointments would be offered and when the GP received a copy of a letter from the Cochlear Implant Team to the Associate Specialist in Paediatrics expressing concern about hearing aid use and clinic attendance, this should have prompted concern and inter-professional communication. It would have been good practice for the GP and at least HV3 to have initiated a discussion about the family, but in this case the lack of communication did not affect service delivery or have any bearing on the outcome. It should also be recognised that the GP was receiving numerous letters which confirmed the intervention of relevant services and some of which reported

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favourably on the child’s wellbeing. It is also reasonable to infer that as several professionals were involved with the family, the GP thought it was unnecessary and would possibly be unhelpful to raise the issue of non-attendance and the child’s deafness during consultations. Unfortunately the GP(s) declined an interview with the IMR author so it is difficult to reach a confident conclusion about these matters. 18.5 GP recording systems were organised in such a way that background information, for example communication and letters, had to be separately accessed and GPs would not routinely do this unless prompted in the main body of the health/consultation record or a marker on the screen. They could thus have been unaware of information about family circumstances or professional concerns if the system did not direct them to other information. The KCHS IMR notes that since the introduction of electronic health visitors’ records, GPs can view health visitors’ entries. Plans to introduce the health visitor ‘child in need’ marker onto GPs’ health records will immediately alert them during consultations to possible safeguarding issues and the importance of accessing other information in the child’s records. The IMR also identifies the need for greater precision about the purpose of information, particularly when GPs are sent copies of correspondence between other professionals, so GPs can be clear about any expectation that they should take further action. 18.6 The first CAF meeting was not held until 7/12/09, following completion of the CAF assessment in November 2009. As has been noted the CHFT and KCHS IMRs consider that the CAF process should have been started much earlier because the child clearly had additional needs associated with profound deafness. The Overview Panel agrees with this observation although the CAF was not integrated into practice at that time. The number of professionals involved with the mother and her child certainly indicated the need for some means of ensuring co-ordination and joint planning. The minutes of this meeting do not identify a lead professional whose appointment is required under CAF arrangements. However, the Directorate of Children and Young People IMR notes that AT1 was the lead professional on completion of the CAF assessment but a change in her employment role led to a hiatus in service provision. Another Advisory Teacher for the Hearing Impaired (AT2) assumed the role of lead professional from March 2010. The identity of the lead professional between the end of November 2009 and March 2010 remains unclear from the IMR although AT2 told the Overview Panel that AT1 retained this responsibility. Minutes from CAF meetings on 7/12/09 and 18/1/10 indicate that AT1 was present. Although it appears that a lead professional was active throughout CAF meetings the lack of clarity about this person’s identity was a matter for concern since the lead professional has a vital role in co-ordinating professional activity and taking responsibility for the CAF process. 18.7 The CAF assessment and initial meetings were not undertaken in accordance with guidance and procedures for intervention under the CAF. The system required that professionals should register their intention to undertake a CAF assessment with the Kirklees Information Sharing System (KISS) which would then check whether the child was subject to any other multi-agency intervention. If so, the professional concerned would be advised to contact an already existing lead professional and to contribute to an established multi-agency process. If the child was not known then KISS would allocate the case a unique reference number which was then used to

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track progress of intervention under the CAF and actions of the multi-agency support team (MAST). This team of professionals involved with the child and his/her family is responsible for meeting regularly under CAF arrangements to discuss the child’s needs and related service provision. The intended CAF assessment for the child subject to this Serious Case Review was not notified to KISS and the CAF health assessment was not received by KISS until 31/3/10. The full CAF forms were subsequently sent to KISS by AT2. The Directorate of Children and Young People IMR notes that AT1 had received only pilot training for CAF (excluding levels 2 and 3) and AT2 had not undertaken any CAF related training. Although CAF training was mandatory for health visitors, HV3 did not complete the training until mid-2010. None of the other professionals who were members of the MAST had undertaken CAF training. Thus, when professionals initiated the CAF assessment and subsequent work in late 2009, they were arguably ill prepared to use the CAF process effectively. In this context Lord Laming comments ‘All agencies need further help in using the CAF effectively and consistently. They also need further support in managing the role of lead practitioners to ensure that all those who undertake this role have the time, training and relationships needed to allow them to support children effectively’ (Lord Laming 2009: 4.9). 18.8 Following the initial CAF meeting on 7/12/09 the MAST delivery plan template was not used to record action, professional responsibility for completing actions by a specified date and expected progress. The KCHS and Directorate of Children and Young People IMRs comment that the initial CAF meeting tended to focus on the mother’s rather than child’s needs and had no identified outcomes against which to measure the effectiveness of CAF intervention. The independent author’s reading of the minutes suggests that while responsibility for actions was clearly identified, these actions were not directly related to outcomes that could be readily measured in terms of the child’s wellbeing. These might have included, for example, a consistent use of hearing aids, the mother’s improved attendance at appointments and availability for home visits and progress in the mother and child’s learning and use of sign language. 18.9 The KCHS IMR comments that if health visitors had sought appropriate supervision with the Named Nurse for Child Protection they might have been afforded an opportunity to reflect on issues associated with working with this mother and been better prepared to provide effective intervention. At the time health visitors were required to seek supervision with the Named Nurse for Child Protection at least once a year and to participate in group (peer) supervision on at least six occasions during the year. The IMR notes that supervision with the Named Nurse might have been particularly helpful for HV2 when the mother refused contact with her following her consideration of a referral to Children’s Social Care and for HV3 following unsuccessful home visits in November 2009. However, the IMR notes that at the time the health visiting team were a close knit unit that preferred internal peer group discussion and supervision. This culture is slowly changing with health visitors now being more proactive in seeking individual supervision with the Named Nurse. Lord Laming commented in his review of safeguarding arrangements, that ‘regular, high quality organised supervision is critical, as are routine opportunities for peer-learning and discussion’ (Lord Laming 2009: 3.15). Although Lord Laming was writing specifically about social work supervision, his comments are no less relevant to other professionals working in a safeguarding context. Numerous other publications have

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emphasised the importance of enabling professionals to reflect on their practice and to develop their analytical skills (see for example, Brandon et al 2009; OFSTED 2010; Munro 2011). 18.10 There is evidence of frequent and effective communication between professionals most closely involved in providing services for this family during 2009. As far as I can see relevant professionals were aware of the activities of other services/professionals and of any concerns arising from their contact with the family. 18.11 There is also evidence from the IMR narratives and chronologies of a sustained effort to help this family, particularly by HV3 and staff from the Children with Sensory Impairment Team. They persisted in attempts to contact the mother when she had missed pre-arranged home visits and consistently reminded her about Audiology, Children’s Hearing Clinic and paediatric out-patients appointments. However, in my view there are two particular factors of importance in this context. First, none of the services involved with this family had the resources to provide practical help so that the mother could consistently attend out-patient appointments. What was needed here was a worker who would bang on the door to wake the mother and refuse to leave until she responded and who would then ensure she had transport to attend Audiology, Children’s Hearing Clinic and paediatric out-patients appointments. Second, we know from HV1’s records that the mother expressed a distrust of people and that HV3 perceived the mother to be a very private person. Clearly, the qualitative nature of professional communication and interaction with the mother would have affected her willingness to develop a relationship with professionals and to share information about her family life. It is impossible in the Serious Case Review process to fully understand how the mother perceived and experienced professional intervention and how this may have affected her willingness to trust those professionals who were attempting to help her and her child. Panel members may have been able to discern clues about the qualitative features of the mother’s interaction with professionals through a direct conversation with her, but this was precluded because of ongoing criminal proceedings during the Serious Case Review. Nevertheless, in the context of social work practice Munro has emphasised that ‘work is done in a relationship with children and family members’ (Munro 2011: 1.19, original emphasis) so that it is vital for professionals to work in such a way as to promote trust, relationships and communication. This must be the situation for all professionals working with children and families and there is little evidence that it was achieved in this case. 19.0

Descriptive account of Year 4: January 2010 to the child’s death on 17/11/10

19.1 The second CAF meeting was held on 18/1/10 and was attended by AT1, the sign tutor, HV3 and the FSW3 from the Children’s Centre. The child’s mother did not attend. The discussion centred on:

• Sure Start had agreed to fund two sessions a week in a pre-school nursery provided that the mother and child attended additional activities at the Children’s Centre.

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• Information provided by HV3 that the mother had refused to see HV2 again following HV2’s suggestion that a referral to Children’s Social Care would be necessary.

• The mother was not treating the child’s need to develop communication skills as a priority and did not ensure appropriate routines.

• Professionals could not gain access to the home for pre-arranged visits and were unable to contact the mother by phone.

• The mother failed to keep an appointment for the child’s two-year developmental assessment.

• The mother had failed to keep appointments with the Cochlear Implant Team. The meeting agreed that the child’s communication skills and development might improve on regular attendance at the nursery and that progress should be reviewed at the next meeting. However, professionals were sufficiently concerned to delegate HV3 to inform the mother that a referral would be made to Children’s Social Care if she continued to miss appointments. 19.2 Clearly, attendance at out-patient appointments and availability for home visits was important to monitor, assess and improve the child’s developmental opportunities. However, it is also important that IMRs should convey an accurate rather than an impressionistic picture of this issue. For example, the KCHS IMR states ‘the minutes [of the CAF meeting] show no one present has had any successful contact with the mother or child since the last meeting’ [on 7/12/09]. This rather gives the impression that numerous professionals had been attempting to see the mother and child without success. In fact the chronology indicates that during this period only two professionals at the CAF meeting (AT1 and the sign tutor) had together attempted one unsuccessful home visit on 14/12/09 and AT1 was subsequently able to contact the mother by phone on 17/12/09 to discuss day care for the child. 19.3 Following the CAF meeting HV3 and AT1 made a joint opportunistic home visit but received no answer. HV3 attempted to visit again on 4/2/10 but could not reach the house due to bad weather. She left a voicemail message arranging to call on 25/2/10. On 16/2/10 the chronology records a telephone conversation between the mother and HV3, when an appointment was made for 23/2/10 to complete the child’s two-year developmental assessment. During this telephone conversation HV3 told the mother about the Police notification regarding an incident on 31/1/10 (see below). HV3’s records indicate the mother was shocked that HV3 knew about this but that it was not discussed any further. When HV3 called as arranged on 23/2/10 there was no reply and no response to voicemail messages. HV3 left a calling card asking the mother to contact her and informed AT1 about this missed appointment. 19.4 The West Yorkshire Police chronology records police attendance at a reported domestic incident at the mother’s home on 31/1/10. Records indicate a disagreement between mother and her former partner. Their disagreement was resolved following police intervention. Police records note that the child was asleep in bed and did not witness the incident. The chronology identifies Police notifications of this incident to Children’s Social Care Duty and Assessment (1/2/10) and the health visiting service (5/2/10).

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19.5 The chronology records that the mother visited the Children’s Centre on 8/2/10 and borrowed books for her child and that she was available for home visits by FSW3 on 12/2/10 and 23/2/10. On 12/2/10 the mother said she had misplaced one of the child’s hearing aids and on 23/2/10 FSW3 noted that although the child was ‘active’ there were no toys in evidence. Although not recorded fully in the chronology FSW3 told the next CAF meeting on 8/3/10 that she had observed the child playing with a medicine bottle. The mother was reportedly unconcerned about this but FSW3 put the bottle out of the child’s reach. 19.6 The mother and child attended an Audiology appointment on 25/2/10 for new hearing aid moulds and an appointment with the Cochlear Implant Team on 8/2/10 (this appointment is not recorded in the chronology but noted in CAF meeting minutes for 8/3/10). 19.7 As far as I can see from the chronology HV3 had not yet had an opportunity to tell the mother about the decision made at the last CAF meeting on 18/1/10 concerning referral to Children’s Social Care if she failed to attend appointments. Following another unsuccessful home visit on 3/3/10 the records indicate that HV3 planned to discuss her lack of access with other CAF members. HV3 anticipated that the mother would attend the next CAF meeting on 8/3/10 and did not therefore make any further appointments. However, HV3 was clearly concerned at this stage and contacted the Children with a Disability Unit duty social worker later on 3/3/10. Records indicate that HV3 expressed her concerns as follows. HV3 had not been able to see the mother and child at any arranged or opportunistic visits since September 2009 (according to the chronology HV3’s last successful home visit had been on 27/7/09 although there had been some subsequent telephone contact). She was concerned that the child did not wear hearing aids and the mother failed to attend health appointments. Overall, HV3 thought that under current circumstance the child was unlikely to achieve the five outcomes in Every Child Matters (Chief Secretary to the Treasury 2003). HV3 informed the social worker about CAF arrangements and the social worker said he/she would discuss matters with the Team manager. The social worker subsequently confirmed that he/she would attend the next CAF meeting. 19.8 The Directorate of Children and Young People IMR and chronology entry regarding this conversation with HV3 includes some additional information. It notes that on the day of HV3’s contact with the Children with a Disability Unit, HV3 informed the social worker that both she and the sign tutor had visited the family home with no response (the sign tutor’s visit is not recorded in the chronology), she had been informed by the sign tutor that toys were not readily available for the child and she had a ‘gut feeling’ the mother was using ‘substances’ based on the nature of her responses. When HV3 was interviewed by the IMR author she indicated that she had not viewed her contact with the Children with a Disability Unit as a referral but that she was seeking advice. HV3 subsequently informed FSW3 from the Children’s Centre that she had contacted the Children with Disability Unit and a social worker would attend the next CAF meeting but the mother was not yet aware of this. HV3 made an opportunistic home visit on 8/3/10 to remind the mother about the CAF meeting on that day but could not get any response.

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19.9 A CAF review meeting was held on 8/3/10 and the minutes record attendance of AT2, the sign tutor, HV3, FSW3 from the Children’s Centre, a social worker from the Children with a Disability Unit, SALT and the mother and her child. The discussion centred on:

• The mother’s failure to keep health appointments and to be available for home visits to which the mother responded that she and the child had been ill recently and were sometimes in bed when HV3 visited.

• There had been no progress with finding alternative accommodation for the family but the mother said her current house was acceptable.

• The mother was not prioritising the child’s needs to develop communication skills, did not ensure that the child was wearing hearing aids and did not establish appropriate routines for the child. The mother said she tried to fit the hearing aids but they kept falling out. When asked why the child did not have hearing aids in at the meeting the mother responded ‘they just aren’t – that’s it’. Professionals at the meeting encouraged the mother to ensure hearing aid use, advising that this would improve the child’s ability to learn and socialise with other children and the sign tutor agreed to provide ‘huggies’ to keep the aids in place.

• FSW3 raised concerns that at her home visit on 23/2/10 there were no toys available for the child and the child was playing with a bottle of Calpol.

• There was rubbish stacked outside the mother’s house which had been there for several weeks.

• A nursery place had been identified for the child for two sessions a week. The mother was unhappy that these sessions were in the morning explaining that she and her child did not usually get up until around 10.00/11.00am.

• The mother and child had been attending ‘stay and play’ sessions at the Children’s Centre for the past two weeks.

• The meeting checked that the mother did not have any financial difficulties and HV3 helped the mother to complete an application for Healthy Start vouchers.

The meeting concluded that nursery attendance would probably improve the child’s development and speech (the child had not yet attended the pre-school nursery despite minutes from the last CAF meeting on 18/1/10 identifying that funding was available for a nursery place) and that progress should be reviewed at the next CAF meeting. 19.10 Supplementary notes of the CAF meeting in HV3’s records identified the mother as avoiding eye contact and appearing to be in a ‘low mood’ – a demeanour which HV3 and FSW3 frequently observed during home visits. When asked if she felt depressed the mother said she was fine, but overwhelmed by the meeting. The mother reportedly drove to the meeting in a car with a male passenger. Upon being asked about this she said she was learning to drive although the car had no ‘L’ plates. There is no indication that professionals enquired about the identity of the man or his involvement with the family. 19.11 The KCHS IMR refers to a further discussion between professionals following the CAF meeting on 8/3/10. It was agreed that the sign tutor would monitor the child’s development and play skills over the next six weeks. HV3 would refer the for

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child for a paediatric review if there was no improvement to try and assess how far the child’s developmental delay was associated with prematurity. The social worker agreed to consult her manager to determine whether there was any continuing role for the Children with a Disability Unit. HV3 informed the social worker about the child’s premature birth and early health problems. 19.12 The Children with a Disability Unit chronology (8/3/10) notes further discussion between the social worker and Deputy Team Manager where it was agreed that the mother should be allowed an opportunity to work with professionals during the period before the next CAF meeting in April. If progress in this context was not evident by then, the social worker would undertake a s.17 (Children Act 1989) core assessment in accordance with the Framework for the Assessment of Children in Need and their Families (Department of Health et al 2000). The social worker would inform HV3 about this decision and ask her to explain this to the mother. HV3 would be requested to let the social worker know whether there had been any progress prior to the next CAF meeting. In the meantime the Children with a Disability Unit closed the case. 19.13 Chronology entries for 10/3/10 and 11/3/10 identify letters to the mother and Children with Sensory Impairment Team and an email to AT2 notifying them that the Children’s Centre had closed the case as funding had been secured for a nursery placement. There is no indication that HV3 was informed about this. 19.14 The social worker from the Children with a Disability Unit contacted HV3 on 22/3/10 and said she would attend the next CAF meeting and would also complete a core assessment if the mother’s co-operation with professionals had not improved. She informed HV3 that the Children’s Centre had closed the case, which concerned HV3 as she had understood the Children’s Centre would continue its involvement and would send a representative to CAF meetings. 19.15 The mother failed to attend the Children’s Hearing Clinic on 23/3/10 for the child’s hearing assessment and did not attend the appointment on 26/3/10 with HV3 for the child’s two-year developmental assessment, which had been agreed with her at the last CAF meeting. A chronology entry indicates that the mother was unavailable when HV3 visited on 26/3/10, although it is unclear whether this visit was pre-arranged. The mother telephoned HV3 and an appointment was agreed for 29/3/10. The mother was unavailable when HV3 visited on 29/3/10. 19.16 Following assessment for a cochlear implant the Associate Specialist in Paediatrics and the GP were informed on 6/4/10 and 12/4/10 respectively that the child was unsuitable for this treatment as the child’s hearing capacity fell beyond the necessary criteria. The Cochlear Implant Team had explained this to the child’s ‘parents’, and advised continuing use of hearing aids. 19.17 The chronology indicates that the mother and child visited the nursery on 22/3/10 and stayed for a morning session on 24/3/10 when the mother said she would like to bring the child for two morning sessions each week as soon as possible. It had been agreed at the last CAF meeting that AT2 and the sign tutor would spend time at the nursery working with the child and nursery staff. AT2 visited the nursery on 19/4/10 but found the child was absent. SALT had also tried

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unsuccessfully to see the child at nursery. AT2 and SALT agreed to make a joint visit to the nursery the following week. The sign tutor visited the nursery on 21/4/10 but the child was absent. 19.18 HV3 completed the child’s two year developmental assessment during an opportunistic home visit on 21/4/10 and recorded observations of the child playing imaginatively and the child and mother using sign language. HV3 noted that the child was not wearing hearing aids although the mother said she usually fitted them. The child had not started attending regular sessions at the nursery although the place had been confirmed at the CAF meeting on 8/3/10 and the mother and child had visited on 22/3/10 and 24/3/10. An Audiology appointment was outstanding, which HV3 agreed to arrange and HV3 reminded the mother about the next CAF meeting on 26/4/10. Completion of the assessment did not identify any major concerns. 19.19 The next CAF meeting was held on 26/4/10 and the minutes record attendance by AT2, the sign tutor, HV3, SALT, social worker from the Children with a Disability Unit and the mother. It was noted that the child had started at nursery that morning with support from AT2, but with no hearing aids, and the mother had stayed for the session. The child had enjoyed nursery, played well and attempted to communicate and the mother was observed to be happier than reported at the preceding CAF meeting. Discussion at the meeting focussed on:

• The mother and child had not been attending activities at the Children’s Centre for nearly three weeks.

• The mother had decided to stay in her current house although the garden remained unsafe for the chid to play in. Rubbish previously noted outside the house had been removed. The mother agreed to try and improve the garden.

• The child’s development was satisfactory apart from delayed speech and learning. HV3 intended to monitor development of the child’s gross motor skills.

• Concern that the child was not consistently wearing hearing aids to which the mother responded the child pulled them to bits and threw them away. The mother agreed to make an appointment at the Children’s Hearing Clinic to obtain new hearing aids. AT2 would request two sets of aids so that one set could be kept at the nursery. AT2 and the sign tutor would continue to work with the child at the nursery as would SALT when time permitted.

• It was noted that the child did not meet the criteria for cochlear implant and the child’s hearing could be substantially improved through the consistent use of hearing aids.

• Discussion with the mother about driving a car without ‘L’ plates and/or without a qualified driver accompanying her before she was able to pass her driving test and the dangers associated with this.

• The mother expressed interest in undertaking a course to learn sign language and it was agreed that the sign tutor would seek information about this.

The social worker from the Children with a Disability Unit concluded that they had no useful role to play in ongoing work with the family but would consider a referral for assessment if there were further concerns. This position was confirmed by the Team Manager on 26/4/10. The CAF meeting agreed to review progress at the next meeting.

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19.20 During the period up to the next CAF meeting on 24/5/10 the chronology indicates that the child attended nursery for five out of a possible seven sessions, the last session being on the morning of the 24/5/10. AT2 provided support during four nursery sessions. The mother had also spent time at the Children’s Centre on 4/5/10 and 11/5/10. 19.21 The mother did not attend the appointment at the Children’s Hearing Clinic on 17/5/10. This was particularly unfortunate as the appointment was to arrange new hearing aids for the child who was reported by mother to have thrown them away before the previous CAF meeting. 19.22 A CAF meeting was held on 24/5/10 when the minutes identify AT2, the sign tutor, HV3 and the Nursery Manager (who was also the child’s key worker) as attending. The mother did not attend this meeting but professionals agreed that ‘progress’ was being made. A lead professional was not identified in the minutes but information from the Directorate of Children and Young People IMR suggests this was AT2. Discussion at the meeting focussed on:

• Nursery was not open during school holidays so the mother should be encouraged to attend sessions at the Children’s Centre over this time. The Nursery Manager reported that the child had settled well, was sociable and interacting with other children, was vocalising and using sign language and was demonstrating independence. Her observations suggested the child’s behaviour was ‘normal’. However, it was noted that the child tended to be clumsy and oversized shoes exacerbated this.

• The child had missed an Audiology appointment on 14/5/10 and a Hearing Clinic appointment on 17/5/10 (the Audiology appointment on 14/5/10 is not recorded in the chronology). It was agreed that HV3 should contact the Children with a Disability Unit about the missed appointments and previous concerns about the mother driving a car without having passed her test.

• The sign tutor had enquired about sign language courses for the mother and would ensure she received a prospectus when this was published.

• SALT had observed the child at nursery that morning and recommended action to improve the child’s speech/communication skills and behaviour. SALT commented that the child appeared to be ‘very happy’.

19.23 A chronology entry for 26/5/10 records HV3’s telephone call to the Children with a Disability Unit as agreed at the CAF meeting. HV3 reported on concerns about the mother’s illegal driving and missed appointments for the child to have new hearing aids fitted. HV3 indicated that overall professionals had seen some improvement in the family. It was agreed to postpone any action until the mother had had an opportunity to attend a further Children’s Hearing Clinic appointment in June and this was confirmed by the Deputy Team Manager of the Children with a Disability Unit. 19.24 Between the CAF meeting on 24/5/10 and the next meeting on 12/7/10, the child attended the nursery for seven sessions out of a possible thirteen. For one of these sessions, the mother and child were attending a Children’s Hearing Clinic appointment. On 16/6/10 and 7/7/10, the chronology records the sign tutor visiting the nursery to find that the child was absent. However, the nursery register records

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the child as attending on both these dates. On 5/7/10 the mother brought the child to the nursery late and with no hearing aids. AT2 expressed her concern about the lack of hearing aids and the mother promised to contact Audiology and sort this out. The mother and child attended a session at the Children’s Centre on one occasion (29/6/10) during this period. 19.25 On 7/6/10 the chronology records a telephone call from the nursery to the Children with a Disability Unit. The Unit then contacted AT2. In summary, the mother had contacted the nursery to say she and the child were due at the Children’s Hearing Clinic that day but were late. They had attended the Clinic and then been asked to go to Audiology for new hearing aid moulds to be taken but the mother had said she did not have time. Staff at the Hearing Clinic thought the mother might be ‘on something’ as she did not appear to understand what was said to her. The Children with a Disability Unit social worker asked AT2 if she wanted to make a referral, to which she replied that she wanted to consult a colleague first. AT2 was supplied with the direct number for the Unit’s duty office. 19.26 Records for the Children’s Hearing Clinic noted the child’s attendance on 7/6/10. The child was not wearing hearing aids and the mother had not taken the child to Audiology for an impression for new moulds. The Associate Specialist in Paediatrics was sufficiently concerned to write to AT2 about the mother’s repeated failure to attend appointments and to copy this letter to SALT, the GP, the Consultant Paediatrician, HV3 and the Children with a Disability Unit. 19.27 AT2 worked successfully with the child and staff at the nursery on 14/6/10 and 21/6/10 and the sign tutor was also able to work with the child on 23/6/10. However, on other occasions AT2 and the sign tutor went to the nursery to find that the child was absent. When this happened AT2 and the sign tutor more often than not went on to visit the family home but could not achieve any response. 19.28 A Children with a Disability Unit chronology entry (24/6/10) refers to a copy letter from the Associate Specialist in Paediatrics to AT2 (see paragraph 19.26). The Deputy Team Manager agreed that the social worker should write to AT2 informing her they had received the letter and noting that if she wished to make a referral she should contact the duty office. The chronology also records a letter dated 24/6/10 from the Children with a Disability Unit to the mother regarding the importance of attending appointments. 19.29 HV3 made an opportunistic home visit on 9/7/10 to remind the mother about the next CAF meeting on 12/7/10, but could not gain access. 19.30 The next CAF meeting was held on 12/7/10 with the minutes recording AT2, the sign tutor, HV3, the Nursery Manager and the mother as attending. A lead professional was still not formally identified in the minutes. Professionals agreed that they were accomplishing ‘progress’ with the mother. Matters discussed at the meeting comprised:

• Concern about the child’s irregular nursery attendance which the mother said was due to a hospital out-patient appointment and illness. The Nursery Manager initiated discussion about applying for funding to enable the child to

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attend nursery for an additional full day (the child was currently attending for two morning sessions a week) and for a worker to provide one-to-one attention for the child and to learn sign language. It was agreed that Kirklees Early Years Service would be approached about this. The mother commented that her child had begun socialising with the neighbour’s children. It was important that the mother and child should attend sessions at the Children’s Centre during the summer holidays when the nursery was closed.

• The mother expressed her satisfaction about arrangements for the child to attend nursery and felt she had benefitted.

• The Nursery Manager reported that the child was playing well with other children, was very gentle, was quick to understand things, was trying to communicate and was responding positively to the word ‘no’. Additionally, the child was always clean, well presented and not hungry on arrival at nursery. The child was now wearing more supportive shoes and was less clumsy.

• The minutes note that the child now had two sets of hearing aids but had arrived at nursery with one whistling and one ill fitting aid. New hearing aids were required. It was made clear to the mother that it was her responsibility to ensure the child was wearing hearing aids and if this was neglected a referral would be made to Children’s Social Care, Children with a Disability Unit.

• The sign tutor was still awaiting the prospectus for the British Sign Language level 1 course and would ensure the mother received this when it became available.

• The mother reported she was no longer driving a car as it had been ‘trashed’. The next CAF meeting was arranged for 11/10/10. 19.31 The nursery register indicates that the child was able to attend for an additional day every week from 16/9/10. In the period until the next CAF meeting on 11/10/10 the child attended nursery for eight out of a possible seventeen sessions. The chronology records AT2 as attending the nursery on 19/7/10 but the child was absent. AT2 was able to work with the child at nursery on three occasions until the next CAF review meeting and the sign tutor was able to do so on four occasions. When the sign tutor expected to work with the child at nursery but the child was absent, the sign tutor made follow-up home visits but could not gain access. However, the chronology records a successful home visit by the sign tutor on 1/10/10 where she noted that the mother and child were developing signing skills. SALT was unable to see the child during this period due to the child’s frequent absence from nursery. 19.32 There is no record indicating that the mother and child had attended any sessions at the Children’s Centre between the CAF meetings on 12/7/10 and 11/10/10. 19.33 The chronology records receipt of a letter by the Children with a Disability Unit from AT2 on 20/7/10 in response to their letter of 24/6/10 (see paragraph 19.28). AT2 wrote that she had no additional concerns but she had informed the mother that if matters (presumably the use of hearing aids and nursery attendance) did not improve she would have no option but to make a referral to the Children with a

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Disability Unit. The Children with a Disability Unit had no further involvement from this date and the case remained closed. 19.34 A chronology entry dated 29/9/10 indicates that the mother had failed to take the child for an Audiology appointment on that day and the child was not wearing hearing aids. One hearing aid had a piece missing. There is no chronology entry from CHFT/Audiology to this effect. 19.35 HV3 made an opportunistic home visit on 6/10/10 and found the child sleeping in the car seat. The mother reported that she had attended the Children’s Hearing Clinic the day before but there is no chronological entry from CHFT/Hearing Clinic to this effect. Additionally, the mother told HV3 the hearing aids whistled, which distressed the child. 19.36 The next CAF review meeting was held on 11/10/10 and the minutes record AT2 (identified as the lead professional), the sign tutor, HV3, the Nursery Manager, Kirklees Early Years Service Inclusion Worker and the mother and child as attending. Minutes again indicate that professionals were happy they were making ‘progress’ with the family. Issues which were addressed at the meeting concerned:

• The child’s non-attendance at nursery. Despite being asked to do so the mother was still not informing the nursery when the child was unable to attend. The Nursery Manager suggested that a pattern of non-attendance was emerging for alternating weeks. The mother responded that non-attendance was due to illness.

• A Statement of Special Educational Needs was being prepared to facilitate a choice of school for the child. HV3 suggested an appropriate school with a hearing unit attached and offered to make an appointment, with which the mother agreed.

• The nursery was now providing free sign language lessons, which the mother was invited to attend.

• It was reported that the child was starting to use sign language more and was becoming more vocal, but had a relatively short attention span. The child had started to bite other children and the mother reported they did this as a game at home. When the child’s behaviour became unacceptable during the meeting the child responded to an instruction in sign language that this should stop.

• The child was reported to have a new set of hearing aids with another set due shortly, with one pair for home use and the other to be kept at the nursery. Although the child tended to pull the hearing aids out at nursery, the Manager/key worker was making progress with encouraging the child to maintain hearing aid use and to check whether they were in. The mother reported that the child would not leave the hearing aids in at home and the aids were ill-fitting and fell out.

• The nursery Manager reported that the child was always clean and well presented on attending nursery and the sign tutor praised the mother’s ability to use sign language.

• Although there were no signing courses available for the mother, she was invited to attend those being provided at the nursery.

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• HV3 had contacted Home Start to enquire about provision for taking the mother and child to hospital out-patients appointments, but there was none.

The next CAF meeting was arranged for 6/12/10. 19.37 During the period between the CAF meeting on 11/10/10 and the child’s admission to hospital on 6/11/10, the child attended four of a possible eight sessions at the nursery. 19.38 The chronology (19/10/10) records a meeting between AT2 and Kirklees Early Year Service to complete the referral for a statutory assessment of the child’s special educational needs. 19.39 The sign tutor was able to work with the child at the nursery on 20/10/10 and made a successful home visit on 22/10/10. On 3/11/10 when the child did not attend the nursery the sign tutor visited the house but received no response. 19.40 On 5/11/10 AT2 had arranged a visit for the mother and child to a preferred school, which had a hearing unit and two teachers for the deaf. The mother did not attend and when AT2 visited the house there was no reply. 19.41 On 6/11/10 the child was initially admitted to the mother’s local hospital and then transferred to Leeds General Infirmary after swallowing liquid plant food. The rapid response vehicle paramedic who had first responded to the emergency call made a referral to Children’s Social Care Emergency Duty Team, which was subsequently relayed to the Children with a Disability Unit. Staff at Leeds General Infirmary also notified Children’s Social Care Emergency Duty Team on 6/11/10 about the child’s admission and the Consultant Paediatrician at the mother’s local hospital informed the West Yorkshire Police Child and Public Protection Unit. Thereafter, West Yorkshire Police initiated an investigation and Children’s Social Care began s. 47 enquires (Children Act 1989) relating to whether the local authority should take any action to safeguard the child’s welfare. The child died on 17/11/10, aged nearly three years old, at Leeds General Infirmary. 19.42 During 2010 the mother took her child to the GP’s surgery for relatively minor Illnesses. The GP received updating correspondence about out-patient management of the child’s deafness and about the mother’s non-attendance at appointments (see particularly copy letter from Associate Specialist in Paediatrics dated 7/6/10). 19.43 Although the observations of some professionals led them to query whether the mother may have been using drugs of some kind because she sometimes appeared disconnected and unable to grasp what people were saying to her, there was no further evidence that this was the case. This observation was made by HV3 during telephone contact with the Children with a Disability Unit (chronology entry: 3/3/10); staff at the Children’s Hearing Clinic (chronology entry: 7/6/10); nursing staff following the child’s admission to hospital on 6/11/10 (chronology entry for Children’s Social Care Duty and Assessment Team: 8/11/10) and AT2 during a telephone conversation with the Children with a Disability Unit (chronology entry: 11/11/10).

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There is no further information about this concern and it is thus difficult to evaluate its significance in relation to the child’s care and wellbeing. 19.44 From June 2010 the chronology includes references to the involvement of Kirklees Early Years Service Child Care Inclusion Officer (CCIO). The CCIO’s role was to support nursery staff in working with the child, assess the child’s need for appropriate equipment and contribute to the preparation of the child’s referral for a statutory assessment of special educational needs. A chronology entry (20/10/10) also indicates that the CCIO was working with the sign tutor to help the child comply with behavioural boundaries. 19.45 As in late 2008 and during 2009 professionals remained concerned about the mother’s inconsistent attendance at appointments and availability for pre-arranged home visits (but see detailed account of mother’s attendance record at the end of this report). This was of particular importance in relation to Audiology/Children’s Hearing Clinic appointments, which were vital for ensuring efficacy of the child’s hearing aids and hence of contributing significantly to the child’s language, speech, learning and social development.1

Excluding opportunistic professional home visits, and nursery attendance which has been referred to above, the mother and child missed the following appointments/visits during 2010:

18/1/10: CAF review meeting 23/2/10: pre-arranged home visit by HV3 3/3/10: pre-arranged home visit by HV3 23/3/10: Children’s Hearing Clinic 26/3/10: meeting with HV3 at the Children’s Centre for the child’s two-year

developmental assessment 29/3/10: pre-arranged home visit by HV3 14/5/10: Audiology 17/5/10: Children’s Hearing Clinic 24/5/10: CAF review meeting 29/9/10: Audiology 5/11/10: visit to proposed school with AT2

20.0

Analysis of Year 4: January 2010 to the child’s death on 17/11/10

20.1 Throughout this year chronology entries and CAF minutes refer to the child as happy, friendly and gentle. The child was able to play and interact with children at nursery, quick to learn and was making progress with speech development and signing. A report from the nursery described the child as having a ‘beautiful smile that made your heart melt’ and as being ‘a little spark of energy’. The nursery’s report also notes that after initial distress at separation from the mother, the child had 1 This comment is made in the context of a dual approach to helping deaf children develop communication skills through speech and signing. However, it should be recognised that there is a debate about the relative impact on the wellbeing of deaf children and adults of striving for ‘normalisation’ through teaching speech/language skills and helping them to enhance their self-esteem, confidence, sense of identity and cultural affiliation with the Deaf community through concentrating on the acquisition of signing/language communication skills (see Department of Health 2005: 7). The sign tutor, who was deaf and wore hearing aids, presented a positive role model for the child.

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confidence she would come back and would run to her for a cuddle when she returned. Regular reports to CAF meetings from the Nursery Manager/key worker described the child as always being clean and well fed when attending the nursery. Here we have evidence of a young child who appeared to be enjoying life and there is nothing to suggest in the child’s demeanour that the child and mother had anything but a reciprocally warm relationship. Despite the parenting challenges arising from the child’s premature birth, there was no evidence from the IMRs of any attachment difficulties between the mother and child, although the KCHS IMR suggests that this may have been an issue. The Directorate of Children and Young People IMR reports that on interview by the author, AT1 said the mother ‘clearly loved her child’. This should not detract from a focus on the child’s needs and parenting capacity, but does indicate the mother’s emotional attachment to her child. 20.2 Nevertheless, as has been noted, delayed development of speech and signing skills would as the child grew older, have impeded learning, social interaction, the development of self-esteem and confidence and eroded opportunities for the child to achieve the five outcomes in Every Child Matters. The mother’s failure to keep appointments jeopardised important aspects of her child’s development. In this context the Directorate of Children and Young People IMR reports that the child’s hearing aids were put through a test box during an out-patients appointment in December 2009, which showed that between February and December 2009 the child’s hearing aids had been switched on for a total of only fifteen hours. Professionals also voiced concern about a lack of household routine insofar as the mother often slept late into the morning and the child did not have breakfast. On 6/11/10 at around mid-day the mother and her partner had been in bed asleep just prior to the paramedic’s arrival at the family home and the mother said the child had not eaten for twenty-four hours. 20.3 The KCHS IMR notes that although concerns about the child’s wellbeing and specific areas of delayed development were well recognised and documented, none of the professionals, including health visitors, identified these concerns in terms of neglectful parenting. The IMR author points here to the definition of neglect in Working Together to Safeguard Children (HM Government 2010: 1.36). Neglect should be understood as the ‘persistent failure to meet a child’s basic physical and/psychological needs, likely to result in the serious impairment of the child’s health or development’ and includes ‘a failure to ‘ensure access to appropriate medical care or treatment’. However, while in certain respects the mother’s care of her child met this definition, the Overview Panel was satisfied that there was no evidence to suggest the child was suffering or was likely to suffer significant harm such that child protection intervention would have been appropriate prior to the child’s hospital admission on 6/11/10. 20.4 A social worker from the Children with a Disability Unit initially became involved following a telephone call from HV3 on 3/3/10 and agreed to attend the CAF meeting on 8/3/10. Following the CAF meeting, the social worker discussed the situation with her Deputy Team Manager and it was agreed that if the mother did not attend appointments and ensure her child wore hearing aids in the period up to the next CAF meeting, the social worker would undertake a core assessment under s. 17 of the Children Act 1989 in accordance with the Framework for the Assessment of Children in Need and their Families (Department of Health et al 2000). This would

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have represented an escalation of concern about the child’s wellbeing and of professional intervention. The social worker attended the CAF meeting on 26/4/10 and concluded there was no further role for Children’s Social Care. However, it was understood that any further concerns would be referred to the Children with a Disability Team and a core assessment would then be commenced. The Overview Panel thought that a core assessment should have been completed at this time since by then the mother had a history of non-attendance at appointments, unavailability for home visits and a failure to ensure that her child wore hearing aids. An in depth assessment was required to understand why the mother behaved in this way, and to evaluate her parenting capacity and motivation to change. It is arguable that the CAF professionals group was looking forward in anticipation of positive change, did not pay sufficient attention to the history of the case and did not reflect on how the history should inform future planning and intervention. A lack of professional attention to case history has been identified as problematic in national evaluations of Serious Case reviews (Brandon et al 2009; OFSTED 2008; 2009; 2010) 20.5 At the CAF meeting on 18/1/10 it had been noted that the child was entitled to an assessment as a child in need under s. 17 of the Children Act 1989 because of profound deafness. However, research indicates that despite the legislative definition of a child who is in need of services, most local authorities will not assess the needs of deaf children unless they have additional problems (Young et al 2008 and 2010). In this case the IMR from the Directorate of Children and Young People indicates that children who are registered as deaf in Kirklees can be offered a service by the Children with a Disability Team, although personal communication between the independent author and a senior manager indicated that this was unlikely to happen unless the child/family were experiencing additional problems which made CAF working inappropriate and met the threshold for intervention by Children’s Social Care. The Manager and social worker from the Children with a Disability Unit should have been more proactive in recognising that a s. 17 core assessment was necessary in the child’s best interests instead of leaving the decision about a referral to Children’s Social Care in the hands of CAF professionals who were clearly ambivalent about taking this step. 20.6 However, matters relating to an escalation of concern and completion of a core assessment under s. 17 of the Children act 1989 are not straightforward. Although a core assessment should have provided more in depth information and analysis than a CAF assessment about the family’s history and current circumstances, parenting capacity and the mother’s experience of family life this would similarly have required the mother’s voluntary co-operation with social work intervention. If the mother had resisted participation in the assessment as historical evidence suggests she may well have done, the next step would have been to consider whether the child was suffering or was likely to suffer significant harm and therefore required intervention under child protection procedures and s. 47 of the Children Act 1989. The Overview Panel agreed that the impact of the mother’s behaviour on her child’s wellbeing did not amount to significant harm and that compulsory intervention was not warranted during the period covered by this Serious Case Review. 20.7 The Directorate of Children and Young People and the KCHS IMRs comment that throughout 2010 the CAF review meetings lacked focus and did not clearly identify the changes which were required in the child’s best interests. While CAF

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meetings on 24/5/10, 12/7/10 and 11/10/10 all recorded that professionals agreed ‘progress’ was being made, there were no clear objectives against which to evaluate ‘progress’ in terms of the child’s development and wellbeing. The minutes for these meetings continued to identify the same causes of concern – the child’s lack of hearing aid use, missed appointments at Audiology and the Children’s Hearing Clinic, unavailability for home visits and irregular nursery attendance. 20.8 Additionally, the chronologies and IMR narratives indicate a contradiction between the identification of ‘progress’ at CAF meetings, ‘threats’ of referral to Children’s Social if matters did not improve (CAF minutes for 18/1/10 and 12/7/10) and the actions of individual professionals. HV3 contacted the Children with a Disability Team on 3/3/10 to express concern and seek advice (although the chronology identifies this contact as a referral) and again on 26/5/10 at the request of the CAF meeting held on 24/5/10 to discuss the mother’s illegal driving and missed appointments at Audiology and the Children’s Hearing Clinic. On 7/6/10 a social worker from the Children with a Disability Team contacted AT2 who expressed her concerns but stopped short of making a referral, and in response to a letter from the Children with a Disability Team (24/6/10) AT2 subsequently responded saying she had told the mother she would make a referral if matters did not improve. 20.9 All of this suggests a degree of muddle and confusion about the conditions under which repeated intentions to refer the child to Children’s Social Care should have been implemented. This is related, at least in part, to the absence of clearly identified outcomes and contingency plans for action if the outcomes were not achieved within specified time frames. The ‘rule of optimism’ and/or ‘fresh start’ thinking may also have played a role insofar as professionals repeatedly gave the mother opportunities to improve her performance in areas that were causing concern and, as is clear from CAF meeting minutes, they anticipated that the child’s communication skills and social development would improve following regular nursery attendance. In the event, the nursery’s report identifies that, overall, the child attended only twenty-six of a possible fifty-four sessions at the nursery. 20.10 It must also be acknowledged that engaging with the CAF process is entirely voluntary for parents/carers whose agreement and participation is necessary for CAF assessments and meetings to continue. All the services provided to the mother and child were accepted (or not) on a voluntary basis. CAF professionals were aware that the mother had refused to see HV2 from October 2008 because of a suggestion that she would consider a referral to Children’s Social Care if the mother did not become more responsive to her child’s developmental and hearing/communication needs. They may have been concerned that if they had acted to make a referral, the fragile engagement with the mother and child would have become completely unworkable. In this context the KCHS IMR questions whether the mother was voluntarily engaged with the CAF process given that she missed meetings on 18/1/10 and 24/5/10 and the meetings went ahead without her, her active participation was not evident from the minutes and professionals continued the CAF meeting on 8/3/10 after the mother had left. 20.11 The CAF process was further confused by a lack of clarity about the identity of the lead professional. Information in the Directorate of Children and Young People IMR suggests that AT1 was initially the lead professional but a change of

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employment role led to a hiatus in service provision with AT2 assuming the role of lead professional in April 2010 (AT2 told the Overview Panel she had become the lead professional in March 2010). The records did not indicate that anyone other than AT1 and AT2 had assumed this role. However, a chronology entry dated 8/11/10 refers to an enquiry by Children’s Social Care Duty and Assessment Team about whether HV3 was still the lead professional for the child’s CAF intervention. HV3 is recorded as responding that this responsibility had transferred to AT2. The Overview Panel was disappointed that basic, but important information, was not clearly recorded and that there may have been some confusion about the identity of the lead professional during periods of the CAF process. 20.12 The Directorate of Children and Young People IMR suggests that the CAF process might have led to the identification of clearer outcomes and professional responsibilities if professionals had followed the KISS procedures and used the CAF template for recording desired outcomes, timescales for achieving outcomes and professional responsibility for actions. This may have been the case, but standardised practice and recording systems should not be expected to replace the significant role of professional judgement and analysis in assessment and decision making. This point has notably been supported by Lord Laming (2009) and Munro (2011). Brandon and her colleagues in national evaluations of Serious Case Reviews (2008; 2009) have also emphasised the importance of critical and systematic thinking and this appears to have been underdeveloped among professionals working with the CAF process. 20.13 The KCHS IMR again draws attention to the importance of supervision during this year. It suggests that HV3 should have sought individual supervision in March 2010 when she contacted Children’s Social Care because of her concerns about the child’s wellbeing, and asked a social worker to attend the next CAF review meeting. Supervision may have enabled HV3 to better understand the significance of her concerns and the aims of the CAF process. OFSTED’s (2010) national evaluation of Serious Case Reviews draws attention to the importance of clinical supervision for health visitors so that they are better able to identify safeguarding concerns. 20.14 There is evidence during this year of continuing and frequent communication between the professionals most closely involved with this family and between professionals working in the community and staff in Audiology and the Children’s Hearing Clinic. However, neither the GP nor HV3 thought to communicate with each other, although I remain unsure about what could have been achieved had they done so. AT2 and the signing tutor particularly made enormous efforts to contact the mother when the child did not attend the nursery, often going straight from the nursery to the mother’s home to check on reasons for non-attendance. Although there was a great deal of inter-agency/professional communication and multi-agency communication at CAF meetings, much of this was taken up with exchanging information about the mother’s missed appointments and expressing professional concern. There is little evidence of communication which focussed on case history, planning and decision making in the context of identified outcomes that were required to meet the child’s needs. 20.15 The KCHS IMR comments that from April 2010 the mother and child’s GP Practice had regular monthly meetings with a link health visitor to discuss any

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children who were registered with the Practice and who were subject to child protection and safeguarding concerns. The child who is subject to this Serious Case Review did not feature in any of these meetings. This was in part because the health visitors involved with the family worked from different teams than the GP link health visitor and she therefore had no knowledge about their involvement with the family. The IMR reports that KCHS has taken immediate remedial action to address this problem. Currently, where health visitors are working with children in respect of whom there are safeguarding concerns, there is a marker of ‘child in need’ on health visitors’ electronic records. This enables the generation of a report identifying all children with this marker for each GP Practice. 21.0

Overall Analysis and Conclusions: Major Issues and Learning Arising from this Serious Case Review

21.1 The Serious Case Review 21.1.1 Any Serious Case Review, by its very nature, is likely to identify improvements that should be made in aspects of organisational and professional performance but this does not necessarily mean that practice was found to be significantly problematic. This section identifies major issues and areas of learning from the Serious Case Review which the Overview Panel identified as relevant to professional intervention and service provision for this mother and her child. 21.2 Could circumstances leading to the child’s death have been anticipated? 21.2.1 It is important to establish from the outset that the Overview Panel concluded the nature and circumstances of the child’s death could not have been anticipated or prevented by professionals who were involved with this family. Nothing in the preceding description of events and their analysis could lead to a conclusion that the circumstances relating to the child’s death were likely to occur. 21.3 Good professional practice 21.3.1 Critical comments that have arisen from the foregoing analysis of practice should not detract from an acknowledgement of good practice where this occurred. Good practice was evident in the following areas: Over the Review period there was consistently frequent inter-

agency/professional communication between all of those professionals most closely involved in providing services to the child and mother.

Information from IMRs points to an ongoing commitment particularly from

health visiting and learning (AT1, AT2 and the sign tutor) to support this mother and to achieve better outcomes for her child. They continually reminded the mother about forthcoming appointments, persisted in trying to make contact with her and when her child failed to attend nursery they visited the family home to identify reasons for non-attendance.

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The Manager/key worker from the child’s nursery regularly attended CAF review meetings and expressed a willingness to expend time and resources on responding to specific needs arising from the child’s profound deafness.

21.4 Early intervention and the CAF process 21.4.1 Although professionals worked well together to support the mother and child, the CAF process implemented from November 2009 was flawed for the following reasons: There appeared to be a lack of clarity about the identity of the lead

professional who should have been responsible for co-ordinating the CAF process.

The lead professional from April 2010 and the health visitor at that time had

not received training in the CAF process. They were therefore arguably ill-prepared to ensure the effectiveness of CAF intervention.

The CAF assessment and subsequent review meetings identified concerns about the child’s wellbeing and potential ability to achieve the five outcomes in Every Child Matters. However, CAF professionals did not identify precise outcomes for the child, for example consistent use of hearing aids, presentation for all hospital out-patient appointments and regular nursery attendance, which would have allowed evaluation of how far they had been achieved. Similarly, the CAF professional group did not identify contingency plans about action which should be taken if these outcomes were not achieved within an agreed timescale. This led to a lack of focus in CAF meetings and uncertainty about the point at which a referral should be made to Children’s Social Care for a core assessment under s.17 of the Children act 1989. Although the Overview Panel acknowledged Munro’s (2011: 5.35) comment that ‘it is the problem of deciding when to escalate the level of professional involvement that is a major challenge in practice’, clarity about what should change to safeguard the child’s wellbeing and identification of insufficient change, must inform such decisions.

There is no evidence that professionals actively challenged the mother about her continuing failure to ensure the child wore hearing aids, her inconsistent attendance at out-patient appointments and the child’s irregular nursery attendance. Although the use of professional authority would have been appropriate here, CAF professionals were aware that the mother had previously rejected contact with HV2 because of a suggestion that she would make a referral to Children’s Social Care. On several occasions between the mother’s rejection of contact with HV2 in October 2008 and the last CAF review meeting, professionals expressed an intention to refer the child to Children’s Social Care if the mother did not improve her parenting. However, there is a difference between what amounted to threats of referral and direct professional challenge based on honesty, openness and a realistic assessment of what might happen in terms of the child’s wellbeing and professional intervention if change could not be achieved.

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The Directorate of Children and Young People IMR suggests that CAF review meetings might have been more effective if they had used the CAF template for recording intended outcomes, timescales, professionals responsible for associated action and progress. However, while the template may have focussed professional attention it would not have improved the outcomes for this child without the ability of professionals to think ‘critically and systematically’ (Brandon et al 2008: 98) about what they were doing. The thinking skills of professionals are vital to ensuring adequate assessment and purposeful intervention (Lord Laming 2009; Munro 2011). In this context Munro (2011: 1.19) comments ‘the emotional dimensions and intellectual nuances of reasoning are undervalued in comparison with simple data about service processes such as time to complete a form’. Many academics and researchers have expressed concern about increasingly rule-governed practice, standardisation and audit arrangements that have undermined the application of professional intelligence and discretion in health and social care (see for example Howe 1992 and 1994; Blaugh 1995; Parton 1998; Smith 2001; Harrison and Smith 2004; Harrison and McDonald 2003). Learning in this context cannot be effectively implemented by local Safeguarding Children Boards alone and the Overview Panel welcomed relevant recommendations made by Munro (2011) in this regard.

Professionals working with the CAF process repeatedly voiced their concern

about the mother and child’s missed appointments with the Consultant Paediatrician and at Audiology and Children’s Hearing Clinics. However, although services did not have the resources to provide practical help in transporting the mother and child to appointments, there is no evidence that professionals focussed on other ways in which they could have facilitated attendance. For example, they did not consider patterns or features of non-attendance in the context of case history, such that the CAF lead professional could have advised out-patient clinics against making early morning appointments and/or ensured that a practitioner was available to make a home visit, bang on the door until the mother answered and ensure she had access to transport for attending appointments.

21.4.2 The CAF is designed to facilitate early intervention such that children with additional needs and their families can receive a multi-agency package of support based on voluntary co-operation. However, there is a danger that the emphasis on support, additional needs and voluntarism leads professionals working in a CAF context to neglect its place at the beginning of a safeguarding continuum (Brandon et al 2008: 102) and to avoid referral to Children’s Social Care when parents are minimally engaged with the process and the child’s immediate wellbeing is not seen to be critically compromised. Brandon et al (2009: 47) suggest in this context that ‘the recent emphasis on strengths based approaches and positive aspects of families (for example in the Common Assessment Framework) arguably discourages workers from making professional judgements about deficits in parents’ behaviour which might be endangering their children’. 21.4.3 Additionally, the Directorate of Children and Young People IMR narrative explains that the Deputy Team Manager and social worker from the Children with a Disability Unit were satisfied that the case should be closed to Children’s Social Care

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because CAF arrangements were in place and CAF professionals had not made a formal referral. In this case the CAF proved to be an obstacle to completion of a core assessment under s. 17 of the Children Act 1989 because professionals misplaced their confidence in CAF working as an effective way to meet this child’s needs. An overly optimistic attitude and a ‘wait and see’ approach combined to exacerbate a misguided adherence to CAF when a Children’s Social Care core assessment was required. 21.4.4 Although in this instance the voluntary and strengths-based nature of CAF intervention may have impeded professionals’ willingness and ability to escalate their concerns, this kind of early intervention remains a vital part of the safeguarding continuum and is central to current Government policy. In this context the Overview Panel thought that the Family Nurse Partnership Programme would have been appropriate to meeting this mother and child’s early needs. Intervention under the Programme begins during pregnancy and continues for two years following the birth of a first child. This programme originated and has been extensively researched in the USA (see Barnes et al 2008: Chapter One for a summary of the USA programme and relevant research). Research in the USA has indicated that for young, first-time, vulnerable mothers this approach has a positive impact on mothers’ parenting skills, the child and mother’s wellbeing and children’s development However, the central difference between Family Nurse Partnerships and professionals delivering universal services is that in the former case professionals must set out to develop a therapeutic relationship with mothers, and if possible fathers/partners, based on continuity, trust, support (rather than judgemental attitudes) and mutual confidence in their willingness and ability to learn. Research on pilot sites in England note that Family Nurses had been able to engage mothers and sometimes fathers/partners where other professionals had been unable to achieve this and that:

Almost all the Family Nurses (FNs) spoke of the importance of the therapeutic relationship they had with their clients. Weekly and fortnightly visits at home had enabled trust, respect and rapport to build up and the strength of this relationship has meant that clients could at times surprise the FN’s with their reliability. (Barnes et al 2008: 64).

Research suggests that these features act to encourage mother’s and fathers’/partners’ engagement with the programme and enable its positive effects (see also Barnes et al 2009 and 2011 for further research on Family Nurse Partnerships in England). Although parental acceptance of Family Nurse Partnerships is entirely voluntary and this approach may exhibit some of the weaknesses identified under 21.4.2 and 21.4.3, the Overview Panel was aware that the opportunity for continuity of professional relationships and trust may have been of particular importance for the shy, private and reticent mother whose child is the subject of this Serious Case Review. NHS Kirklees began to offer family Nurse Partnerships to clients in August 2009 and reached programme capacity in April 2010 with 150 clients. 21.4.5 Although the Overview Panel was clear that a s. 17 core assessment should have been completed it was equally clear that for the period covered by the Serious Case Review the child was not subject to significant harm such that child protection procedures should have been followed.

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21.4.6 CAF assessment and review meetings are based on multi-agency working. The principles of multi-agency collaboration are equally important outside of CAF arrangements where numerous agencies/professionals are working with a family, for example in relation to pre-discharge planning meetings when a child with additional needs is leaving hospital to return home. A pre-discharge planning meeting was not arranged in this case. 21.4.7 Learning here relates to the importance of professional understanding about the purpose of CAF intervention and the point at which the CAF should be superseded by a referral to Children’s Social Care for a core assessment under s.17 of the Children Act 1989 or child protection enquiries under s. 47 of the Act. Additionally, professionals operating under the CAF must have the necessary supervisory support to ensure reflective and intelligent thinking about intended outcomes for a child, time scales, evaluation of outcomes and contingency plans if the outcomes are not achieved. Professionals need to be alert to the importance of multi-agency planning outside CAF arrangements when several agencies/professionals are involved in working with families where children have additional needs. 21.4.8 Recommendations to address these issues are as follows:

• Recommendation from the Overview Panel for KSCB: KSCB should ensure, through work with the Children’s Trust that CAF is

further embedded across agencies in Kirklees, with a particular focus on improved quality, recording, clear outcomes, appropriate challenge and triggers for further assessment.

• Calderdale and Huddersfield NHS Trust

Guidelines and documentation should be developed for pre-discharge

planning from the Neonatal Unit. These will be developed by the Paediatric Liaison Sister and the Safeguarding Lead for the Neonatal Unit.

Guidance for CAF training will be incorporated into the Safeguarding Training strategy for Calderdale and Huddersfield NHS Trust.

The Foundation Safeguarding Training provided by Calderdale and Huddersfield NHS Trust will be reviewed.

• Kirklees Council Children and Young People Service, Family Support

and Child Protection The CAF process should be embedded in practice and CAF documents

quality assured to ensure they are fit for purpose. All professionals must use the specific CAF documentation.

All professionals should be appropriately trained prior to being appointed as the lead professional. If this is not possible, then Kirklees Information Sharing Service (KISS) should offer ongoing advice and support to the lead professional until such time as they are suitably trained.

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Professionals who suspect a child is being neglected should be able to evidence their assumption in a way that highlights the strengths and concerns to all professionals known to that family and an agreed approach to responding to concerns made.

• Sheffield Teaching Hospitals NHS Foundation Trust

The Trust will ensure that staff within NNU have undertaken CAF training and

that the Safeguarding midwife will be informed of any CAF undertaken by NNU staff.

21.5 Histories of parents/carers 21.5.1 Although agencies, including Children’s Social Care, GP Practices, West Yorkshire Police and West Yorkshire Probation Trust held historical information about the child’s mother at the time of the Serious Case Review, this information was not accessed by professionals who were working with the family. It was only the Children’s Centre Community Link Worker who contacted Children’s Social Care to enquire about the mother’s history following information from the health visitor that she had previously contacted the agency without a satisfactory response. National evaluations of Serious Case Reviews and related literature have made it clear that any assessment and understanding of parenting capacity must be informed by knowledge about parents’/carers’ own experience of parental relationships and family life. However, it must be acknowledged that a CAF assessment is not designed to gather in depth information about a parent’s/carer’s history or to analyse its impact on parenting capacity. This would have required a core assessment under s. 17 of the Children Act 1989 and underlines the importance of escalating intervention under the CAF to s. 17 if it becomes evident that the CAF process is unable to secure those outcomes which are required to safeguard the child’s wellbeing and development. 21.6 The role of extended family members 21.6.1 The IMRs indicate that professionals had very little knowledge about or involvement with members of the mother’s extended family. There was no assessment of their actual or potential role in supporting the mother and the contribution that they might make to the child’s wellbeing, beyond the mother’s assertion during the CAF assessment that she received help and advice from some family members. However, a report to the Overview Panel from Home Start suggests that during a home visit in June 2008 the mother indicated she was receiving less support from family members than she would have liked. The Overview Panel was concerned that professionals were working with a presumption of extended family support when a more thorough and analytical approach may have indicated otherwise. Additionally, in some instances professionals neglected to record and to consider information about family members’ (including fathers’/partners’) ethnicity and religion which may have been relevant for intervention and service provision. 21.6.2 Professionals need to be aware that the role of extended family members should not be presumed and should constitute part of a holistic assessment.

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Additionally, they should be alert to any issues associated with ethnicity and religion that are relevant for considering professional practice and service delivery. 21.6.3 The following recommendations seek to address this issue:

• Recommendation from the Overview Panel for KSCB: Partner agencies are to report to KSCB in six months time on how their

service is working to ensure that: 1. Professionals working with a family request information regarding ethnicity

and cultural and religious identity and record a parent/carer’s response. 2. Professionals understand and record arrangements for extended family

support. 3. Professionals request and record information about significant adults who

come into contact with children including a child’s father and the mother’s partner(s) and record a parent/carer’s refusal to provide this information.

• Kirklees Community Healthcare Services

KCHS Standard Operating Procedures will be reviewed to ensure that

‘assessment of need’ includes discussions with the parent/carer about the support available from other family members. These discussions must also include the level of paternal involvement and the ethnicity and religious identities of children and parents/carers and must be recorded in the electronic health record.

• Sheffield Teaching Hospitals NHS Foundation Trust

An internal safeguarding audit will be undertaken to consider gaps in the

recording of social history, ethnicity and allied agency involvement with families.

21.7 Professional attention to fathers/partners 21.7.1 Apart from Sheffield Children’s Hospital, none of the services/agencies involved with this child either sought or were able to identify information about the child’s father. During professional intervention with the family there were occasions when the mother told the health visitor she had a new boyfriend, the Community Link Worker from the Children’s Centre recorded an unknown male as answering the door at a home visit, the mother was seen driving to a CAF meeting with a man and the health visitor received notification from West Yorkshire Police about an incident in January 2010. Similarly, nursing records from the mother’s local hospital, Calderdale Royal Hospital and Leeds General Infirmary identify visits from the father and ‘parents’ and this is the case for some hospital out-patients appointments and GP consultations. Although the mother was reticent about divulging information regarding her relationships, it is striking that professionals showed so little interest in the role that the child’s father and other men might have been playing in the child’s life. This lack of attention to the significance of men in family relationships reflects repeated findings from national evaluations of Serious Case Reviews (Rose and Barnes 2008; Brandon et al 2009; OFSTED 2010). The Overview Panel thought that

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the lack of professional curiosity and interest in the role of the child’s father/mother’s partner(s) was an important omission in relation to professional practice. 21.7.2 Although the Overview Panel tried to uncover further information about the mother’s former partner and subsequent partner(s) and their involvement in the child’s life, in the absence of an opportunity to talk to family members during the Serious Case Review it could not discover anything in addition to information presented in the IMRs and agencies’ reports. Despite the importance of understanding a partner’s capacity for parenting, their impact on the child’s wellbeing and the way in which they may affect the mother’s parenting (see Brandon et al 2009: 112), the Overview Panel was unable to reach any conclusions in this regard. 21.7.3 Professionals need to understand the importance of the role that fathers/partners may play in family life and include attention to their involvement in assessment and planning. 21.7.4 Recommendations to encourage learning in this context are:

• Recommendation from the Overview Panel for KSCB: Partner agencies are to report to KSCB in six months time on how their

service is working to ensure that: 1. Professionals working with a family request information regarding ethnicity

and cultural and religious identity and record a parent/carer’s response. 2. Professionals understand and record arrangements for extended family

support. 3. Professionals request and record information about significant adults who

come into contact with children including a child’s father and the mother’s partner(s) and record a parent/carer’s refusal to provide this information.

• Kirklees Community Healthcare Services

Record keeping in General Practice must be made in accordance with

professional standards, and include documentation of all persons present, and their relationship to the child, during any consultation with a child or young person.

21.8 Supervision, reflection and professional development 21.8.1 The IMR from KCHS comments throughout on the importance of individual supervision for enabling health visitors to clarify the evidential basis for their concerns about the child’s wellbeing and to reflect on the relationship between concerns and appropriate action. In this case health visitors tended to seek peer group consultation rather than individual supervision with the Named Nurse for Child Protection. The IMR notes that current KCHS policy encourages health visitors to seek individual supervision in complex cases and that the culture of relying on peer group consultation is now changing with the recognition that individual supervision should be sought more frequently. In relation particularly to social work Munro (2011) emphasises the crucial nature of opportunities for frequent and regular supervision, for reflection on complex interventions and for the active pursuit of

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continuing professional development. Additionally, Higher Education Institutions should pay acute attention to their recruitment arrangements and to the provision of analytically challenging and knowledge/evidence based qualifying programmes. Munro’s comments here are equally relevant to other professionals who work with children and families in a safeguarding context. 21.8.2 Learning here requires that professionals and organisations value and implement arrangements, which encourage supervision, reflection, continuing professional development and attention to developing professionals’ evidence based knowledge and analytical (thinking) skills. 21.8.3 A recommendation in this context is:

• Kirklees Community Healthcare Services KCHS Safeguarding Children and Young People Policy will be reviewed to

strengthen the need for health professionals to seek supervision from the Named Nurse Child Protection when vulnerable families with complex needs are identified.

21.9 Attachment issues 21.9.1 The terms of reference for this Serious Case Review identify appropriate attachment behaviours between the mother and child as an issue for the Overview Panel’s consideration. As has been noted there was no evidence from the IMRs to suggest that attachment problems between the mother and child had a detrimental effect on the child’s wellbeing and emotional development. Most of the information generally points to a mutually warm relationship, the child’s trust that the mother would return at the end of nursery sessions and the child’s ability to form relationships with other adults, for example staff at the child’s nursery. All of this indicates secure attachment behaviour. However, it must be acknowledged that there is little evidence to suggest professionals were alert to possible attachment issues and this should have attracted attention given the child’s premature birth, feeding difficulties, early irritability and profound deafness. Because the Overview Panel could not identify evidence that professionals had assessed the mother and child’s early attachment behaviour, its conclusions must be tentative in this regard. 21.9.2 The Overview Panel queried the fact that the IMR from KCHS noted the absence of evidence to indicate that health visitors had assessed the quality of attachment between the child and mother, but had not accompanied this observation with a recommendation for learning. KCHS subsequently identified a recommendation in this context: KCHS should strengthen the quality of assessment in relation to attachment.

All training delivered by the Named Nurses should incorporate both the assessment and recording of attachment.

21.10 The role of General Practitioners

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21.10.1 The KCHS IMR draws attention to the lack of communication between the mother’s GP Practice and other community-based professionals, particularly the health visitor(s) who were working with the family. The GP and the health visitors did not initiate communication with each other. Additionally, the IMR is critical that although the GP was aware the mother repeatedly missed Audiology, Children’s Hearing Clinic and Paediatric out-patient appointments this did not prompt the GP to discuss the matter with the mother during consultations or with the health visitor(s). The Overview Panel considered that in this case the role of the Consultant Paediatrician and the Associate Specialist in Community Paediatrics in overseeing the child’s care, and good communication between all the other professionals, meant that additional communication with the GP would have added little or nothing to knowledge about the case and would have lacked a clear purpose. Additionally, as has been noted, GPs’ electronic consultation records would not have provided contextual information about, for example, letters from other professionals identifying missed appointments unless GPs had been prompted to look for this information elsewhere in the records. The KCHS IMR notes that link health visitors can now access the names of all children subject to safeguarding concerns who are registered with a GP Practice. In Kirklees the wellbeing of these children is discussed at monthly meetings between the link health visitor and GP(s). Nevertheless, the Overview Panel acknowledged that GP Practices are often the recipients of significant information about a child and family and should be alert to safeguarding issues associated with repeatedly missed appointments. With this in mind the IMR includes the following recommendation:

• Kirklees Community Healthcare Services: The Named Nurse Child Protection Kirklees Community Healthcare Services

must ensure that all training developed and offered to General Practice services highlights the need for issues of neglect to be a consideration with respect to missed medical appointments.

21.11 Referrals to Children’s Social Care 21.11.1 The Directorate of Children and Young People IMR and the chronology indicates that following the child’s admission to hospital on 6/11/10, information about the incident was initially conveyed to Children’s Social Care Emergency Duty Service. This Service then notified the Children with a Disability Unit and the Family Support and Child Protection Duty and Assessment Team, each of which responded separately to the referral. This then led to a discussion about which service should be responsible for conducting s. 47 (Children Act 1989) enquiries regarding child protection issues with the conclusion that enquiries should be led by a social worker from Duty and Assessment with a social worker from the Children with a Disability Unit in support. Although this matter is not relevant to the circumstances which led to the child’s death, the IMR author considers that duel points of referral may have led to some initial confusion and delay about locating responsibility for responding to child protection concerns. The IMR author therefore makes the following recommendation:

• Kirklees Council Children and Young People Family Support and Child Protection:

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There is a need to consider a single point of entry into Family Support and

Child Protection for professionals seeking advice or making referrals about individual children/families. The single point of entry should be the Duty and Assessment Service.

21.11.2 It should be noted that although the Overview Panel decided to include this recommendation as arising from the Serious Case Review, Kirklees Directorate of Children and Young People is currently undertaking a review of the organisation and effectiveness of early intervention and family support services. Part of this review will consider issues relating to a single point of referral, clear referral pathways and integrated assessment in services for children and families and will thus respond to the recommendation above. 22.0

Evaluation of the Serious Case Review process

22.1 As the independent author I am satisfied that the Overview Panel was thorough and objective in its attention to the terms of reference and in achieving the purpose of a Serious Case Review as set out in Working Together to Safeguard Children (HM Government 2010: 8.5). 22.2 OFSTED in its national evaluations of Serious Case Reviews has frequently commented on the problematic quality of IMRs. IMR authors in Kirklees had preparatory briefing sessions and an on-line pro-forma and guidance for completing IMRs, but there was still room for improvement. Although relatively few in number the quality of IMRs (and some reports) required the Overview Panel to spend considerable time in relation to quality assurance and requesting authors to improve accuracy, to clarify information and to be more acute in their analytical observations. I think this issue is part of a bigger problem with regard to IMR authors’ analytical skills, the time and support which they are afforded to complete their work and the degree of oversight and challenge from managers who are required to ‘sign off’ the IMRs. There is every reason to think that Munro’s (2011) comments about the importance of professional judgement and intelligence over standardised process requirements are as relevant to the Serious Case Review process as they are to everyday professional practice. Nevertheless, it was constructive to invite IMR authors to meetings of the Overview Panel and enabled members of the Panel to seek clarification and to discuss important aspects of professional intervention with this family. 22.3 At the time of writing this report the Overview Panel has been unable to involve family members in the Serious Case Review because of ongoing criminal proceedings against the mother for neglecting her child. This has led to a situation where the Overview Panel agreed that the Serious Case Review should be concluded on the basis of available information and submitted to OFSTED for evaluation. However, the Overview Panel planned to invite family members’ participation in the Serious Case Review at the conclusion of criminal proceedings, and should any further information arise at this stage either from the family or from evidence released during or following criminal proceedings, the Overview Panel will re-convene and this overview report may require an addendum to include any additional information that is of relevance to further learning.

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23.0

Other Serious case Reviews completed by Kirklees Safeguarding Children Board (KSCB)

23.1 To date, KSCB has identified learning issues arising from Serious Case Reviews relating to serious incidents that occurred between November 2006 and July 2008. Several learning issues identified in previous Serious Case Reviews are relevant to this Review and require further attention in the context of effective learning. These are: Professionals’ knowledge about and willingness to initiate intervention under

CAF arrangements. It appears that the CAF is gaining ground in Kirklees but needs to be at the forefront of professionals’ minds when early intervention is required in response to a child’s additional needs. Additionally, professionals need training to effectively understand and implement CAF arrangements. In Kirklees this training is provided by the Kirklees Information Sharing Service and all relevant professionals are being provided with appropriate training on a rolling programme.

A lack of professional attention to the interest that fathers/former partners may

have in the child’s wellbeing and the involvement of ongoing partners in family life. As has been noted this is a common finding in national evaluations of Serious Case Reviews and cannot simply be remedied by the introduction of additional procedures/guidance. Professional attention to this issue depends rather on an understanding that the role/involvement of the child’s father and mother’s partner(s) in the child’s life may have significant consequences for the mother’s parenting capacity and the child’s wellbeing.

The complexity of professional judgements about the likelihood of potential

harm to a child and decisions about escalating the level of concern. This issue has been discussed by Munro (2011) who has asserted the need for measures to improve professionals’ evidence based practice, analytical thinking and intelligent reflection about how best to respond to complex problems in a child’s best interests.

The importance of supervision and opportunities for continuing professional development that can enable professionals to develop learning in a challenging but supportive environment.

23.2 These outstanding learning issues, which have also been identified in national evaluations of Serious Case Reviews as presenting a continuing challenge, largely reflect problems associated with the understanding and thinking skills of managers and front-line practitioners. Although practitioners’ thinking skills may be improved by effective supervision and opportunities for continuing professional development, sophisticated analytical skills and the ability to make finely balanced professional judgements cannot simply be ‘injected’ into professional performance by additional local/national procedures and compliance audits. In this context Munro’s (2011) recommendations to Government which seek to improve intelligent, analytical and compassionate professional practice were welcomed by the Overview Panel.

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23.3 Kirklees Safeguarding Children Board has responded to these learning issues with appropriate recommendations, action plans and arrangements for monitoring their implementation. The KSCB Serious Case Review Work-stream produces an annual report, which evaluates the effective implementation of recommendations/action plans arising from Serious Case Reviews and if necessary the Work-stream may commission additional work to check that action plans have led to necessary changes in organisational and professional practice. Additionally, KSCB has implemented a continuing programme of multi-professional training to help professionals learn from the findings of local and national Serious Case Reviews. However, it should be acknowledged that some continuing difficulties with regard to professional practice identified both locally and by national evaluations of Serious Case Reviews require changes at a national policy level. 24.0

Complete list of recommendations

24.1 Recommendations for KSCB from the Overview Panel Partner agencies are to report to KSCB in six months time on how their

service is working to ensure that: 1. Professionals working with a family request information regarding ethnicity

and cultural and religious identity and record a parent/carer’s response. 2. Professionals understand and record arrangements for extended family

support. 3. Professionals request and record information about significant adults who

come into contact with children including a child’s father and the mother’s partner(s) and record a parent/carer’s refusal to provide this information.

KSCB should ensure, through work with the Children’s Trust that CAF is

further embedded across agencies in Kirklees, with a particular focus on improved quality, recording, clear outcomes, appropriate challenge and triggers for further assessment.

24.2 Recommendations from Calderdale and Huddersfield NHS Trust Guidelines and documentation should be developed for pre-discharge

planning from the Neonatal Unit. These will be developed by the Paediatric Liaison Sister and the Safeguarding Lead for the Neonatal Unit.

Guidance for CAF training will be incorporated into the Safeguarding Training

strategy for Calderdale and Huddersfield NHS Trust.

The Foundation Safeguarding Training provided by Calderdale and Huddersfield NHS Trust will be reviewed.

24.3 Recommendations from Kirklees Community Healthcare Services Record keeping in General Practice must be made in accordance with

professional standards, and include documentation of all persons present, and their relationship to the child, during any consultation with a child or young person.

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The Named Nurse Child Protection Kirklees Community Healthcare Services

must ensure that all training developed and offered to General Practice services highlights the need for issues of neglect to be a consideration with respect to missed medical appointments.

KCHS Safeguarding Children and Young People Policy will be reviewed to strengthen the need for health professionals to seek supervision from the named nurse child protection when vulnerable families with complex needs are identified.

KCHS Standard Operating Procedures will be reviewed to ensure that ‘assessment of need’ includes discussions with the parent/carer about the support available from other family members. These discussions must also include the level of paternal involvement and the ethnicity and religious identities of children and parents/carers and must be recorded in the electronic health record.

KCHS should strengthen the quality of assessment in relation to attachment. All training delivered by the Named Nurses should incorporate both the assessment and recording of attachment.

24.4 Recommendations from Kirklees Council Children and Young People, Family Support and Child Protection The CAF process should be embedded in practice and CAF documents

quality assured to ensure they are fit for purpose. All professionals must use the specific CAF documentation.

All professionals should be appropriate trained prior to be appointed as the

lead professional. If this is not possible, then Kirklees Information Sharing Service (KISS) should offer ongoing advice and support to the lead professional until such time as they are suitable trained.

There is a need to consider a single point of entry into Family Support & Child Protection for professionals seeking advice or making referrals about individual children/families. The single point of entry should be the Duty and Assessment Service.

Professionals who suspect a child is being neglected should be able to evidence their assumption in a way that highlights the strengths and concerns to all professionals known to that family and an agreed approach to responding to concerns made.

24.5 Recommendations from Sheffield Teaching Hospitals NHS Foundation Trust The Trust will ensure staff within NNU have undertaken CAF training and that

the Safeguarding midwife will be informed of any CAF undertaken by NNU staff.

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An internal safeguarding audit will be undertaken to consider gaps in the

recording of social history, ethnicity and allied agency involvement with families.

25.0

Conclusion

25.1 This child’s death was tragic, but the Overview Panel concluded that circumstances leading to it could not have been foreseen by any of the professionals who were involved with providing services to the mother and her child. This Serious Case Review has identified learning in several areas of professional practice which are discussed throughout this report and particularly under paragraph 21. In this context the Serious Case Review process focussed the Overview Panel’s attention on four major themes. First, the role of CAF and multi-agency working in early intervention and the challenges that professionals face when they have to decide whether to escalate their concerns about a family by making a formal referral to Children’s Social Care for a s. 17 core assessment or a child protection response. Social workers and managers in Children’s Social Care should have been much more proactive in recognising the need for a core assessment under s. 17 of the Children Act 1989 in this case. Second, the importance of recognising parental neglect which may not obviously present to professionals as a safeguarding issue and as having significant long-term effects on a child’s wellbeing and development, but which may nevertheless affect a child’s life chances. The professionals most closely involved in providing support to this mother and her child did not identify a parental failure to keep appointments and to ensure that the child wore hearing aids as constituting neglect. Third, the relatively unusual occurrence of profound deafness in a child who is subject to a Serious Case Review which meant that the Overview Panel had to gain an understanding of the implications of missed appointments with Audiology/the Children’s Hearing Clinic for the child’s social, emotional and cognitive development. The Department of Health (2008a) notes that professionals will rarely have to work with deaf children and their families and, for example, an average GP Practice with five GPs is likely to deal with only one deaf child in ten years. Fourth, in keeping with Munro’s (2011) observations, the Overview Panel identified problems with professionals’ analytical thinking and ability to identify and evaluate the desired outcomes of professional intervention for this child. 25.2 In some parts of this overview report I have made personal comments and the Overview Panel has not dissented from these remarks. 26.0

Detailed record of the mother’s attendance at appointments and availability for pre-arranged home visits

26.1 Throughout this report I have highlighted the mother’s non-attendance at appointments with Paediatric out-patients and the Audiology, Children’s Hearing and Child Development Clinics together with her unavailability for pre-arranged home visits (see paragraphs 15.26: 15.33: 17.19: 19.46). These missed appointments constituted a significant cause of concern for professionals since they were important to monitor the child’s growth and development and for ensuring the child’s ability to develop communication, learning and social skills. However, although the text of this

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report refers to all appointments and home visits, whether attended or not, the Overview Panel thought it important to present a detailed summary of the mother and child’s contact with professionals at specialist healthcare appointments and home visits. This is recorded in the Table below. It should be noted that the Table includes pre-arranged home visits. Professionals, particularly HV3, made some opportunistic home visits which have been identified in this report. However, I have not included these in the Table as professionals could not reasonably have expected the mother to be available for opportunistic visits.

Appointments attended/missed by the mother and child and availability for home visits during the Serious Case Review period

Date Type of appointment/home visit Attended

or available

Not attended or unavailable

2008 21/4/08 Home visit by Neonatal Outreach Nurse Available 23/4/08 Home visit by Neonatal Outreach Nurse Available 24/4/08 Audiology appointment Attended 25/4/08 Home visit by Advisory Teacher for the Deaf (AT1) Available 29/4/08 Home visit by Neonatal Outreach Nurse Available 2/5/08 Joint home visit by health visitor (HV2) and

Neonatal Outreach Nurse Available

8/5/08 Joint home visit by health visitor (HV2) and Neonatal Outreach Nurse

Not available

8/5/08 Joint home visit by AT1 and Neonatal Outreach Nurse

Not available

8/5/08 Audiology appointment Attended 8/5/08 Out patients appointment with Consultant

Paediatrician Attended

No dates

Letter from Children’s Physiotherapy/Occupational Therapy re missed appointments (chronology entry 7/5/08)

Not attended

12/5/08 Home visit by Neonatal Outreach Nurse Available 16/5/08 Home visit by Neonatal Outreach Nurse Available 20/5/08 Home visit by HV2 Available 21/5/08 Home visit by AT1 Available 22/5/08 Children’s Hearing Clinic appointment Attended 27/5/08 Home visit by Neonatal Outreach Nurse Available 30/5/08 Home visit by HV2 Available 2/6/08 Home visit by Neonatal Outreach Nurse Available 4/6/08 Home visit by Nursery Nurse (Health Visiting

Service) Available

10/6/08 Home visit by AT1 Available 10/6/08 Home visit by Neonatal Outreach Nurse Available 12/6/08 Home visit by Home Start Co-ordinator Available 13/6/08 Joint home visit by Neonatal Outreach Nurse and Available

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HV2 17/6/08 Home visit by Neonatal Outreach Nurse Available 26/6/08 Home visit by AT1 Not available 27/6/08 Joint home visit by Neonatal Outreach Nurse and

HV2 Available

2/7/08 Appointment with Consultant Paediatrician Attended 9/7/08 Appointment with HV in Clinic Attended 11/7/08 Home visit by AT1 Available 18/7/08 Mother and child discharged from Neonatal Outreach Service 25/7/08 Home visit by HV2 Available 29/7/08 Appointment at Children’s Hearing Clinic Attended 1/8/08 Home visit by HV2 Available 5/8/08 Home visit by AT1 Available 8/8/08 Home visit by HV2 Available No date Appointment at Children’s Hearing Clinic to collect

hearing aids (chronology entry 22/8/08) Not attended

22/8/08 Home visit by HV2 Available 2/9/08 Joint home visit by AT1 and sign tutor Available 5/9/08 Home visit by HV2 Available 9/9/08 – Dec 08

Weekly visits arranged by sign tutor but often no reply when sign tutor visited

Often unavailable

9/9/08 Letter from Paediatric Dietician – re last appointment

Not attended

15/9/08 Home visit by AT1 Available No date Appointment at Child Development Centre

(chronology entry 19/9/08) Not attended

19/9/08 Home visit by HV2 Available 29/9/08 Appointment at Children’s Hearing Clinic Not attended 8/10/08 Appointment with Consultant Paediatrician Not attended 10/10/08 Home visit by HV2 Available No dates Letter re two missed appointments at Child

Development Centre (chronology entry 10/10/08) Not attended

24/10/08 Joint home visit by HV2 and Children’s Centre Family Support Worker (FSW1)

Available

25/10/08-11/12/08

AT1 tries to contact mother by phone on numerous occasions to make an appointment but cannot get any reply

4/11/08 Joint home visit by FSW1 and Family Support Manager

Available

No dates Chronology entry (5/11/08) re three missed appointments at Child Development Centre

Not attended

6/11/08 Home visit by AT1 Available 10/11/08 Joint home visit by FSW1 and Children’s Centre

Community Link Worker (CLW1) Not available

11/11/08 Joint home visit by FSW1 and CLW1 Available 17/11/08 Joint home visit by AT1 and Speech and Language

Therapist (SALT) Not available

19/11/08 Appointment with Consultant Paediatrician Not attended 26/11/08 Appointment at Children’s Hearing Clinic Not attended 8/12/08 Appointment at Baby Clinic Attended No date AT1 contact with Child Development Centre re Not attended

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further missed appointment (chronology entry 9/12/08)

(4 appointments)

16/12/08 Joint home visit by AT1 and sign tutor Available 31/12/08 Appointment with Consultant Paediatrician Not attended

(3 consecutive appointments)

2009 7/1/09 Home visit by CLW1 Available 8/1/09 Home visit by AT1 Available 19/1/09 Appointment at Children’s Hearing Clinic Attended 22/1/09 Home visit by sign tutor Available 29/1/09 Home visit by sign tutor Available 30/1/09 Home visit by AT1 Available 12/2/09 Home visit by sign tutor Available 17/2/09 Joint home visit by AT1 and SALT Mother

cancelled 26/2/09 Home visit by AT1 Available 2/3/09 Audiology appointment Attended 12/3/09 Home visit by AT1 Available 26/3/09 Home visit by AT1 Not available 1/4/09 Home visit by sign tutor Available 1/4/09 Appointment at Children’s Hearing Clinic Attended No date Report of child’s assessment by SALT (chronology

entry 7/4/09 -17/4/09) Available

18/4/09 Home visit by sign tutor Available 20/4/09 Home visit by sign tutor or AT1 (not identified) Available 30/4/09 Home visit by sign tutor Available 6/5/09 Home visit by AT1 Not available 6/5/09 Appointment with Consultant Paediatrician Not attended

(4 consecutive appointments)

7/5/09 Home visit by sign tutor Available 14/5/09 Home visit by sign tutor Available 16/5/09 Home visit by sign tutor Not available 20/5/09 Home visit by AT1 Mother

cancelled 21/5/09 Home visit by AT1 Not available 27/5/09 Home visit by HV3 Available 4/6/09 Home visit by sign tutor Not available 18/6/09 Home visit by sign tutor Available 2/7/09 Home visit by sign tutor Not available 3/7/09 Home visit by AT1 Mother

cancelled 20/7/09 Joint home visit by AT1 and SALT Available 3/8/09 Home visit by AT1 Not available 10/8/09 Appointment at Children’s Hearing Clinic Attended 3/9/09 Home visit by AT1 Not available 4/9/09 Home visit by AT1 Available 9/9/09 Appointment with Consultant Paediatrician Not attended

(5

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consecutive appointments)

16/9/09 Home visit by AT1 Not available 16/9/09 Audiology appointment Attended 24/9/09 Joint home visit by AT1 and sign tutor Available 6/10/09 Home visit by AT1 Available 15/10/09 Home visit by sign tutor Available 17/10/09 Home visit by AT1 Not available 19/10/09 Home visit by AT1 Not available 2/11/09-5/11/09

AT1 tries to contact mother by phone on numerous occasions to make an appointment but cannot get any reply

16/11/09 Joint home visit by AT1 and Children’s Centre FSW3

Available

20/11/09 Home visit by HV3 Not available 7/12/09 CAF meeting Attended 14/12/09 Joint home visit by AT1 and sign tutor Not available

2010 18/1/10 CAF review meeting Not attended 8/2/10 Home visit by sign tutor Available 12/2/10 Home visit by FSW3 Available 23/2/10 Home visit by HV3 Not available 23/2/10 Home visit by FSW3 Available 25/2/10 Audiology appointment Attended 3/3/10 Home visit by HV3 Not available 8/3/10 CAF Review meeting Attended 23/3/10 Appointment at Children’s Hearing Clinic Not attended 26/3/10 Appointment for two-year developmental

assessment with HV3 Not attended

29/3/10 Home visit by HV3 Not available 26/4/10 CAF review meeting Attended 14/5/10 Audiology appointment (recorded in CAF minutes) Not attended 17/5/10 Appointment at Children’s Hearing Clinic Not attended 24/5/10 CAF review meeting Not attended 7/6/10 Appointment at Children’s Hearing Clinic Attended 12/7/10 CAF review meeting Attended 29/9/10 Audiology appointment Not attended 1/10/10 Home visit by sign tutor Available 11/10/10 CAF review meeting Attended 22/10/10 Home visit by sign tutor Available 5/11/10 Appointment to visit school with HV3 Not attended NOTES:

1. The child was referred to the Cochlear Implant Team in August 2009. Although CAF Minutes for the meeting on 18/1/10 refer to missed appointments with the Cochlear Implant Team, appointments have not been included in the Table because the chronology does not include consistent entries about attendance/non-attendance.

2. The child began to attend two half-days at nursery per week from 26/4/10 and this was supplemented by an additional full day per week from 16/9/10. The relative absence of home visits by AT2 and the sign tutor during this period was because they were working with the child at the nursery.

3. The report from the child’s nursery states that the child attended 26 sessions of a maximum 54 sessions that could have been attended.

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References

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