Serious case review
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Bolton at Home 3.2.1 The agency is a registered social housing provider, having taken over ownership and management of Bolton local authority housing. It provides a range of housing services to 18,000 tenants. 3.2.2 The IMR has been prepared by the Customer Support Manager who has responsibility for services to older and vulnerable customers and countersigned by the Director of Housing Services. 3.2.3 The report has been prepared from paper records:-
Computer records consulted were:-
3.2.4 The author was unable to interview the two staff members who provided services as one had retired and the other (Support Officer 2) had left for another post. However the staff member who has retired (Support Officer 1) had all but one of the contacts with the family and was interviewed as noted above, prior to the SCR but after the serious incident notification to local services from BSCB; the notes provide some detail for the IMR. 3.2.5 Additionally because Adult 2 was aged under 25 years, the family was referred to the Tenancy Sustainment Service and, following completion of an assessment, a ‘Successful Tenancy Plan’ (STeP) was completed. However the paper record of the assessment and plan completed when the tenancy was taken up cannot be found after a search in the agency. These documents would have provided more detailed information given directly by Adult 1 and Adult 2 and their acceptance of a level of support. 3.2.6 Initial contact with Adult 2 was in writing when he accepted the offer of the tenancy. When the tenancy was ready for use Support Officer 1, assisted Adult 2 to apply for a furniture package and completed the STeP. 3.2.7 Support Officer 1 visited three times soon after the family moved in but had no contact, leaving a card asking them to make contact. 3.2.8 Support Officer 2 visited for a two month review and noted that although the family had not responded to the request for contact, the tenancy was well maintained and the family reported they had support. Over the next nine months Support Officer 1 made eight visits, of which the family were at home for five. In addition to this Adult 1 proactively sought advice from Bolton at Home to:-
3.2.9 The records note that during the visit Adult 2’s sister and husband with their baby were present and had been for all visits to date; it is noted that Adult 1 is looking forward to the birth of Child 1; and when the damp was noticed in the kitchen, that the baby was due. 3.2.10 The records do not always note who was present when contact was made, but they suggest that the family have good support from Adult 2’s sister and from neighbours. However the notes also indicate that Support Officer 1 may have thought that Adult 2 was in breach of his tenancy agreement by allowing his sister and family to live with them. Adult 2 denied this and Adult 5 was not seen following the comment. 3.2.11 The report concludes that the service monitored and offered support appropriately to Adult 1 and Adult 2, but that there are three areas for improvement, forming recommendations. These are that:-
3.3 Children’s Services – Staying Safe 3.3.1 The Staying Safe Division of Children’s Services has responsibility for Children’s Centres, Family Support Teams and all Social Work teams (including Referral and Assessment (R&A), Safeguarding, Looked After Children, Emergency Duty team (EDT), Leaving Care, Youth Offending Team (YOT), Independent Reviewing Officers (IROs) and other Child Protection workers (including Local Authority Designated Officer for safeguarding, Local Safeguarding Children Board Officer, Safeguarding in Schools Officer, CAF Co-ordinator). The work spans levels 2-4 of Bolton’s Framework for Action; however, the Family Support, Social Work and IRO teams only work at levels 3 and 4. 3.3.2 The IMR has been prepared by the Head of Service, Child Protection and Leaving Care, who has responsibility for Safeguarding, Common Assessment Framework (CAF), IROs and the Leaving Care Service. It is countersigned by the Director of Children’s Services. The report reviews services provided by Children’s Centres, the R&A Team and the EDT. 3.3.3 The report has used electronic social work records of case notes, emails, contact records, initial assessment and strategy discussions, as well as paper and electronic records from two Children’s Centres:-
Additionally two Children’s Centre managers and a family worker, three social workers and two emergency duty social workers were interviewed. 3.3.4 The first contact with Children’s Services was when Adult 1 and Child 2 registered at Children’s Centre 1, the nearest centre to their address while living with Adult 5. They attended nine drop in activities. After a four month gap, they attended one more drop in activity and Child 2 went into the crèche while Adult 1 attended one ESOL (English for Speakers of Other Languages) class. There was no concern reported from any of these sessions and this pattern of attendance is normal. The service is available for parents (usually mothers) to use when they wish with no action if they do not attend. It was also noticed when preparing the IMR that Adult 1 had attended once at Children’s Centre 3. 3.3.5 Adult 1 began attending for ante-natal care at Children Centre 2 coming five times until a week before the birth of Child 1. At Children’s Centre 1, Adult 1 used the name she had used for her Children Centre registration but at Children’s Centre 2 she sometimes used a different name, but the same as the one she used for NHS records. 3.3.6 About two weeks after Child 1 was born, a referral was made to the MARP for family support from Children’s Centre 2. When the family worker contacted the home to arrange a visit, Adult 2 answered the telephone and only said ‘No, No, No’. The family worker then agreed to make a joint visit with the referrer, Midwife 8, but for personal reasons was not able to contact Adult 1 before Child 1’s death. 3.3.7 The referral had not indicated a level of priority at a time when the Children’s Centre resources were stretched. A follow up to the brief details originally recorded on the referral noted that:-
3.3.8 On the day of Child 1’s admittance to hospital, the R&A social work team was contacted by Hospital 3 notifying of the imminent death of Child 1, with brief details of the circumstances of admission to the local hospital, medical condition and that at present the cause of death did not appear suspicious. 3.3.9 Hospital 3 notified the emergency duty team that because of the retinal bleeding found by an eye specialist, non-accidental injury could not be ruled out. Later EDT was notified that Child 1’s death had occurred. Senior managers were informed of the death. Following senior manager’s discussions and decisions the GMP Public Protection Investigation Unit was informed. Both GMP and Children’s Services knew that a post mortem would be conducted and no action would be taken until information was available from it to confirm the cause of Child 1’s death. 3.3.10 As soon as the EDT knew that Child 1 had died, agency checks were made with Area 4 Children’s Services as Hospital 3 indicated that the family had returned there with Child 2. Following some negotiation and when the death of Child 1 was identified as potentially non-accidental, Area 4 Children’s Services’ EDT visited the family with the local police. They observed that Child 2 was safe and well. The negotiation for a home visit by Area 4 Children’s Services was supported by GMP PPIU. Adult 1 and Adult 2 were advised to return to Bolton (and that they cannot have direct care of Child 2). 3.3.11 The R&A team and EDT only had contact with the family from the time of Child 1’s admission to hospital and the procedures were followed properly with senior managers informed and updated appropriately. 3.3.12 The review of the Children’s Centre services has raised some suggestions for change. The agency is conscious that the service is a universal service provided with the intention of welcoming parents from the community who may be less willing to attend if they thought their parenting was being monitored. However the IMR makes four recommendations that:-
3.4 Reports included in the NHS Bolton Commissioning Report General Practitioner 3.4.1 Child 1’s family were registered with two different general practitioner practices (GPs), the first was close to the address of Adult 5. They registered with the second practice which is close to Address 1 after they moved into their own tenancy. 3.4.2 The IMR was prepared by the GP clinical advisor for NHS Bolton and countersigned by the Associate Medical Director, NHS Greater Manchester. The author interviewed two GPs and the Advanced Nurse Practitioner (ANP) from the current practice, and read the records for Child 1 and Child 2, and Adults 1 and 2 from both practices. The chronology only contains contacts directly involving Child 1, but the narrative includes some historical information from the first GP practice where it is relevant to the key lines of enquiry. 3.4.3 Child 2 had been diagnosed with an iron deficiency as part of routine health visiting screening and had been referred to dietetics. Child 2 was also receiving speech and language therapy input. The GP notes do not indicate any concern for wellbeing. 3.4.4 Historically Adult 2 had input from his GP in Area 4 for his learning difficulty but there were no recordings linked with this in the Bolton records. 3.4.5 The only significant record for Adult 1 was a record made (in the first Bolton practice) where she had told the GP that Adult 2 had hit her and she did not want another pregnancy. She was given advice and a telephone number to ring if she wanted support. 3.4.6 Child 1 was seen three times at the surgery. The first occasion is recorded as a query about jaundice and the midwife visiting the surgery agreed to follow up as a routine part of their service. The second visit resulted in an admission to Hospital 1 as the child was vomiting and had ‘motley’ skin which can be an indication of a serious illness. Child 1 was discharged the same day with a prescription for anti-reflux treatment which the parents collected from the GP practice two days later. 3.4.7 The day of Child 1’s final admission to hospital parents had earlier requested a GP appointment. Following the request for a same day appointment, the Advanced Nurse Practitioner (ANP) saw Child 1 with Adult 2. She saw from the notes that there had been a previous concern with vomiting and she concluded that the problem was a continuation of reflux. She examined Child 1’s chest and abdomen but did not remove all clothing. She advised a review if the condition deteriorated. 3.4.8 None of the practitioners considered that there were any cultural or language issues, with both parents communicating clearly and understanding responses. There was also no evidence of Adult 2’s learning difficulty noted in the records. 3.4.9 The narrative picks up two issues that should have been responded to differently. The first is that with such a young baby, the ANP should have removed the clothing to examine fully and have made an accurate record of alertness. The post mortem of Child 1 suggests that the death would not have been prevented by such action, but it is good practice. 3.4.10 The second issue is that GP Practice 1 gave advice to Adult 1 about seeking help when she revealed some domestic abuse, but did not note it in the records in such a manner that it would alert other practitioners in the practice, and did not notify the health visitor. This should be a routine response especially as there was a pre-school child in the family. If the health visiting service had knowledge of the issue more enquiries probably would have been made when Child 1’s pregnancy was known. 3.4.11The IMR suggests that cultural issues could potentially have prevented Adult 1 from seeking further help or advice. It is known that the GP gave Adult 1 a Children’s Services telephone number to ring for advice. It would have been more appropriate if details had been given of culturally appropriate services which are available in the local community. The records do not note if the GP explored further the content of the information, for example the frequency or severity of the abuse. 3.4.12 The IMR notes that both GP practices provided a good quality primary care service to the family; in particular good practice in guaranteeing that young children are seen on the same day and that practitioners are all well qualified and experienced in paediatric health. However the IMR identifies the issues in paragraphs 3.4.9, 3.4.10 and 3.4.11 as recommendations to share with all Bolton GP practices. 3.5 Bolton NHS Foundation Trust 3.5.1 Bolton NHS Foundation Trust was created from local community and hospital based services. This SCR is the first completed since the services came together under one management structure. The IMR has used the SCR opportunity to check consistency of understanding and use of procedures within different sectors of the organisation. This means that some learning is not directly linked to the SCR but will contribute to improved safeguarding responses across the new Trust Arrangements. 3.5.2 The IMR has been prepared by the Trust’s Named Nurse Safeguarding Children and countersigned by the Associate Director of Patient Safety/Deputy Chief Nurse, Bolton NHS Foundation Trust. To complete the report, the author has read:-
The author interviewed the health visitor, the health visiting staff nurse, the midwife and paediatrician. The author did not review the records of the therapy services provided to Child 2, and the panel confirmed that sufficient detail of service delivery and parenting of both children had been gained from the primary health service records and interviews. 3.5.3 The records from the health visiting and midwifery service are completed to a good standard, and include good detail of who was present, the focus of the contact and a summary of discussion. 3.5.4 The health visiting service contacts mainly concerned Child 2 starting with a detailed assessment being completed. Both adults reported they were in good health and Adult 1 said she had no concerns in relation to personal safety or domestic abuse. It is not known if Adult 2 was present while domestic abuse and personal safety issues were discussed. The family was not unusual in that Adult 2 was present less often, but when there he demonstrated appropriate care and concern for Child 2. 3.5.5 The focus of most visits was attention to some developmental needs of Child 2, linking with speech, diet, play and sleep pattern. Appropriate referrals were made to specialist services and when the health visitor was giving detailed advice on diet, she arranged to visit with an Urdu speaking interpreter. However the record confirmed that Adult 1 spoke English sufficiently well to understand the content of health visiting and midwifery contacts. 3.5.6 Discussions covered matters concerning benefits, progress on audiology and speech therapy appointments and encouragement to attend activities at the local children’s centre to give Child 2 more opportunities to play. 3.5.7 Adult 1 attended all her ante-natal appointments and was well during the pregnancy. It was recorded that both adults were happy to be having a second child. The records note however that there were continuing difficulties with Child 2’s development and behaviour. Child 2’s blood count had improved with a varied diet and medication. 3.5.8 Adult 1 indicated that she and Adult 2 planned to separate as he was reported to have started a new relationship. In the same conversation Adult 1 said she was concerned that if Adult 2 took Child 2 to the family in Area 4 when she went into hospital for the birth of Child 1, she may not be able to get Child 2 back. Adult 1 reported that Adult 2 planned to return to live with his family, but that he would look after Child 2 in Bolton during her hospital admission. 3.5.9 Towards the end of the pregnancy Adult 1 discussed finding a nursery placement for Child 2. Just before Child 1’s birth, Child 2 missed some routine health appointments but this was not considered an indicator of compromised parenting, but rather due to the imminent birth. 3.5.10 Child 1 was born by normal delivery at Hospital 1 and was discharged home. When the midwife visited the family was sleeping downstairs as they said the bedroom was damp. Child 1 was over wrapped and advice on safe sleeping was given as expected in BSCB’s recent initiative called ‘Sleep Safe’. 3.5.11 Adult 1 took Child 1 to the surgery. She saw the GP about a concern that Child 1 had jaundice, and separately she saw Midwife 1 about the umbilicus. The records note that Adult 1 was tearful. Adult 1 described the earlier abuse from Adult 2’s family and said she wanted her family to come to stay from Area 3. The midwife reported this information to her colleague who visited the family, but had no further discussions about family circumstances. 3.5.12 Child 1 developed well, putting on weight appropriately. Just prior to discharge from the midwifery service to the health visitor and GP, Midwife 8 discussed the issues Adult 1 had raised with her colleague. Following this discussion Midwife 8 made a referral for family support. 3.5.13 Health Visitor 2 completed her primary visit and recorded discussion of key issues on safe sleeping, feeding, immunisation and skin care, as well as the family situation. The adults reported they were applying for rehousing as a family. 3.5.14 The records indicate no concern of the care of either Child 1 or 2. Child 2 was referred by an ophthalmologist to a paediatrician because of some unusual behaviour, for example hand flapping, limited language, tantrums and repetitive behaviour. Child 2 had not been seen by the paediatrician at the time of Child 1’s death. In line with the universal service as part of the Healthy Child Programme, Health Visitor 2 had no further direct contact with the family, but kept in touch by telephone and from records received from the GP practice. 3.5.15 Other than the birth of Child 1, Hospital 1 had contact with the family when Child 1 was admitted following presentation at the GP surgery with vomiting. Child 1 was discharged the same day with a prescription for anti-reflux therapy. The final contact was the admission of Child 1 for cardiac arrest. 3.5.16 The IMR acknowledges the wide range of issues discussed by health visitors and midwives with Adult 1. While there were some clues that Adult 1 felt isolated there were also a number of protective factors, including attending the Children’s Centres for activities, attendance at ante-natal care, family members visiting and using community resources. 3.5.17 Staff Nurse 1 took care to ensure that an interpreter was present to speak in Urdu when she was giving detailed information but Adult 1 had a good understanding and kept dietary records in good English. Other than the abuse in Area 4 the staff had no concerns about the adults as parents. When matters of diet or over wrapping were pointed out, the family responded appropriately and immediately. Adult 1 found it more difficult to consistently implement the advice given in respect of Child 2’s routines but she co-operated with staff at all times. 3.5.18 While Adult 2 was seen less often (four times), there were no concerns about his parenting; he demonstrated a good relationship with Child 2. Importantly none of the staff identified any issues as a result of him having a learning difficulty. Learning difficulty was not evident in his ability to manage and respond to the needs of Child 2. This was a professional judgement made from a number of observations and not formal assessment or further enquiry being undertaken to consider if his learning difficulty had any impact on his parenting. 3.5.19 The only indicator of risk noted was that both parents were young, but both approached parenting with maturity. Adult 1 had three opportunities to talk about domestic abuse from Adult 2, but on each occasion said she had no concerns for her personal safety. At the last direct contact, both adults seemed relaxed and comfortable with each other. Staff are experienced in signs of abuse or difficult relationships, but did not find this to be the case for Adult 1 and 2. 3.5.20 The IMR identifies three areas where the service could have made further assessments or enquiries. These are:-
Overall however there was no evidence of significant harm. 3.5.21 The report notes that the family were provided with good health services, with a child centred focus, good relationships with community NHS staff, referrals as needed for other services, and attention given to culture and language. However as noted in paragraph 3.5.1 the SCR has given an opportunity to consider the provision of a child focussed service in the context of the whole Bolton NHS Foundation Trust. 3.5.22 The recommendations relate to:-
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