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Serious case review


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4. Conclusions and Analysis
4.1 To what extent did agencies/services/individuals recognise and take account of Adult 1’s potential vulnerabilities? In particular:-

    • Age

    • Language and literacy needs

    • Immigration status

    • Marital status

    • Level of isolation or integration within the local community

    • Relationship and support offered from wider family members


And what impact did this have on assessments, planning, intervention and outcomes?
4.1.1 Generally agencies consider that staff in contact with Adult 1 had an understanding of her vulnerabilities. However when each of the bullet points is taken in turn, much less was known than emerged in the SCR process.
4.1.2 The only agency to comment on the young age of Adult 1 was Bolton at Home. Because of the ages of both Adult 1 and Adult 2, they were offered additional support as part of the STeP programme to help maintain the tenancy, as young people rather than as young parents. The visiting officer had recorded brief details of visits and contacts, which suggested the couple, were managing the tenancy well and asking for help when it was needed.
4.1.3 All the agencies who met Adult 1 knew that English was not her first language, but their records show that her spoken, and when seen, her written English is of a good standard. The Children’s Centre registration details record her first language as Urdu and her English as ‘basic’ but it is not known if this was her judgement or a staff member’s. She did attend an ESOL on one occasion. It is not known if her failure to attend more classes was due to her assessment of them not being necessary, or for other reasons. As the service is available for those who wish to use it, rather than as part of a plan, it was not appropriate to follow up any non-attendance.
4.1.4 As part of the service for Child 2, the health visitor wished to ensure Adult 1 understood detailed dietary information and advice. For this visit an interpreter who spoke Urdu accompanied the health visitor, but at the visit it was agreed that Adult 1 had no need of the service and clearly understood the information and advice being shared.
4.1.5 However when Child 1 was taken to hospital and Adult 1 was distressed, she did wish to revert to her first language. The staff member in the ambulance was able to talk by use of closed questions and gestures, but could have used Language Line. At Hospital 3 one of the consultants spoke Hindi and by choice she used this language to speak to the family on admission. At other times all staff members used English and considered Adult 1 understood.
4.1.6 Once again, the only agencies that were aware of Adult 1’s immigration status (discretionary leave to remain) were the housing agencies. Her status had been confirmed as part of the housing application. NHS agencies only record immigration status if the person is recorded as either an asylum seeker or refugee as there are specific health arrangements for people with such status.
4.1.7 The UKBA notes that at the time of Child 1’s death her immigration could not be described as ‘precarious’, but a mother of two small children, only having eighteen months security remaining, may have a different view. However agencies providing universal services had not asked her about this.
4.1.8 The only agency in Bolton who had any details of Adult 1’s marriage was Bolton NHS Foundation Trust. Adult 1 told her midwife after the birth of Child 1 that it had been an arranged marriage that took place in Area 3. However staff also viewed Adult 1 as mature and engaging well with services.
4.1.9 The background details from Area 4 give this information as it had been recorded by Area 4 Police when Adult 2 had been interviewed in relation to supplying a controlled drug but was not known generally to agencies in Bolton.

4.1.10 In relation to the last two bullet points, I have taken them together. The housing agencies knew of the support offered by Adult 5, both in providing accommodation when the family moved to Bolton because of the abuse from Adult 4, supporting the housing application and providing support after the family moved into Address 1. At one point a Bolton at Home staff member asked if Adult 5 and her family were living at this address as they had been present each time she called. Adult 1 had also told the agency she had good contact with neighbours. The STeP service was intended to ensure the family had sufficient support to maintain the tenancy, but that is the whole extent of their interest.


4.1.11 Children’s Centres are part of Bolton’s universal provision to support families. While their remit is to help parents to parent well and provide opportunities to mix and socialise, it is specifically not a service which asks for any personal details unless the adult offers the information or there are child protection concerns. When the midwife made the single agency referral, there was no indication that Adult 1 was socially isolated, but just that she would benefit from some support.
4.1.12 Within the NHS, the first GP in Bolton probably had the best indication of Adult 1’s isolation, when she told him that her husband had hit her, she was lonely and she did not want another baby. The GP notes also included some information about the abuse in Area 4. However this was not coded for future practitioners to see; this meant that when Adult 1 began to talk to other health services her conversation was not seen in the context of her earlier conversation. Direct information about Adult 1’s experience in Area 4 was only given by her to Midwife 1 (at GP). It was when Midwife 8 followed up this discussion on her visit that the single agency referral was made as Adult 1 had said she felt isolated.
4.1.13 Staff Nurse 1 had noted when she was working with the family to improve Child 2’s diet, that Adult 6 was visiting to help reinforce the programme of change. This was recorded as positive family support.
4.1.14 When the family was at Hospital 3, the vulnerability of Adult 1 was recognised, first by the staff member from NWTS who stayed with her, and then by Hospital 3 staff. They fully understood her need to be fully included, respected her request for all information to be given to her and Adult 2 before discussion with the wider family, and consulted when decisions about withdrawal from life support had to be made.
4.1.15 On reflection, agencies have identified that their services could further improve by:-


  • NHS community staff have a wider understanding of the range of stressors that can cause vulnerability within a family

  • Children’s Centres ensure full and accurate factual details are taken when families register for attendance

  • NHS agencies use Language Line for emergencies as well as for more routine

  • Ethnicity is recorded, including first language

4.1.16 However, as will be noted later in the report, there is a balance to be made of intrusion into the lives of those who do not ask or appear to need support, and the need to know so that support can be offered and made available.


4.2 To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:-

    • Age

    • Learning disability/difficulty

    • Marital status

    • Parenting capacity

    • Level of isolation or integration within the local community

    • Relationship and support offered from wider family members


And what impact did this have on assessments, planning, intervention and outcomes
4.2.1 For Adult 2 comments made in paragraphs 4.1.8 and 4.1.10 above also apply. He still met the criteria for inclusion on the STeP programme. Other than the note about his age from Bolton at Home, no agency had recorded any comment about his age.
4.2.2 English is Adult 2’s first language but he also speaks Urdu and Punjabi. The cognitive assessment completed as part of the court process notes that Adult 2 ‘can express himself quite adequately and although he sometimes uses words idiosyncratically his meaning is generally quite clear’. This is relevant for the agencies responding to any recognition of Adult 2 having a learning disability/difficulty.
4.2.3 As part of the housing application Community Housing Services checked the status of Adult 2’s learning difficulty with him, his sister, and the GP. The notes state he has a ‘relatively low level raising no significant concerns for independent living nor in terms of parenting capacity’. Any further comment is not available as it would be on the assessment that cannot be found in Bolton at Home records.
4.2.4 Children’s Services only knew that Adult 2 had a learning difficulty from a note on Midwife 8’s single agency referral. When the Family Worker telephoned to arrange to visit in response to the referral, her assumption at his response was that he did not speak good English. On reflection it may have been because he knew nothing of the referral, or didn’t want any agency involved in the family.
4.2.5 While Bolton NHS FT knew from Adult 1 and Adult 2 that Adult 2 had a learning difficulty, both had described as ‘difficulty in reading and writing’. Adult 5 had told Bolton Childrens Services that Adult 2 had a learning difficulty, and described it as ‘being about seven years younger than his chronological age’. It was only when the family was at Hospital 3, when Adult 4 described him as having a mental age of 12, while Adult 1 described him as two years behind that there was any suggestion that his capacity as a parent might be limited. The staff at the hospital recorded that when the family was arranging to leave, he seemed confused about where he should go, but this is the only recording that suggests he was unable to understand fully expectations and his responsibilities. The panel considered Adult 2’s response could equally be a response to an emotional and draining situation.

4.2.6 In relation to Adult 2’s parenting capacity, observations from the health visiting service, who saw him four times, the midwife and Bolton at Home staff were all positive. He was seen to care for and play with Child 2, and when Child 1 was ill the second time, it was Adult 2 who took the child to the surgery. All the staff who observed Adult 2 were trained in Child Protection and were aware of which signs to look for to identify any safeguarding concerns. The NHS Bolton Commissioning Report concludes that more information would have been helpful in the context of including fathers more in child health assessments. This has been identified in a number of Serious Case Reviews, and noted in the fourth Biennial study of SCRs published by Ofsted in June 2009. It had studied 189 SCRs completed between 2005 and 2007. Two of the key findings were that there was a dearth of information about men in most serious case reviews, and a failure to take men into account in an assessment.


4.2.7 Adult 2 was not considered to be socially isolated. The housing agencies noted that he had and appreciated support from his sister. Support Officer 1 also found the whole family was out on six of 12 visits, suggesting they had people to visit or places to go. NHS community staff found he was often out when they visited and assumed he was not isolated.
4.2.8 In summary, Adult 2 presented as an adult who was able to communicate with staff from the different agencies, was an active parent to Child 2, and after the birth, to Child 1, and appeared to have support both from family and the community.
4.3 What opportunities did the agency have to observe parenting capacity and interaction between Adult 1 and Adult 2 with Child 1 and Child 2? What impact did this have on assessments, actions and services offered at the time? Is there anything that could have been done differently?
4.3.1 Records and staff interviews confirm that observation of Adult 1 and Adult 2 as parents were positive. Some agencies (Community Housing Services, Bolton at Home, Children’s Services) only saw the adults with Child 2, but it was noted in particular that Adult 2 had a good relationship with this child, with a note from Staff Nurse 1 that Child 2 was missing Adult 2 when he was absent from the home.

4.3.2 The GP record indicates that they were seen as a normal, caring family; the limited observation at Hospital 3 gave no indication of anything different.


4.3.3 The more detailed records are from the two Health Visitors and the two midwives. Adult 1 is recorded as mature and in control of family matters, but showing warmth and with a positive relationship with Child 2. This assessment was confirmed by observations from ward staff when Adult 1 stayed with Child 1 in Hospital 1 during admission. When Adult 1’s demeanour was different, it was recorded, as ‘tearful’ and ‘sad’. The conclusion that both parents were competent is based on the full health visiting assessment, and then working with the adults using the Solihull Resources (a Parenting Support Programme) to help make changes with Child 2.
4.3.4 Adult 2 was seen by Community Health staff four times, and was not seen alone; however his parenting was observed to be appropriate with good interactions with Child 2.
4.3.5 When Adult 1 and Adult 2 first moved to Bolton their relationship was assumed to be a strong one. Together they had defied Adult 2’s family and left the extended family home to live as a family unit. The first indication that their relationship had some difficulties was, when Adult 1 told GP1 that she did not want another baby, that Adult 2 had hit her a few times, she felt lonely, that her parents were abroad and that Adults 3 and 4 had thrown them out. This was not explored further by the GP and not coded in the notes to draw the attention of later practitioners.
4.3.6 Further information was given when Adult 1 told Staff Nurse 1 that Adult 2 was ‘seeing someone else’ and they had discussed separating after Ramadan. She was also concerned that Adult 2 would take Child 2 back to Area 4 when she was in hospital for the birth of Child 1, and that he would not bring Child 2 back to her.
4.3.7 Adult 1 told Staff Nurse 1 that they were planning a separation by mutual agreement. Just after Child 1’s birth, Adult 1 revealed some of her isolation when she told Midwife 1 of the reason for the move from Area 4. She also wanted her mother to come from Area 3 to help her. When Midwife 1 asked her about the conversation she said she felt isolated.
4.3.8 This conversation prompted the single agency referral to MARP. However when Health Visitor 2 made the primary visit following the birth of Child 1, the plans had changed to seeking rehousing as a family. At no time was there any negative interaction between the adults, and it is possible that the disclosures could be seen as more associated with Adult 1’s greater vulnerability immediately before and after the birth of Child 1.
4.4 To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues?
4.4.1 On the whole agencies had recorded diversity issues. Community Housing Services had confirmed the immigration status of Adult 1, checked with family and GP for information on Adult 2’s possible disability, noted both adults had a good standard of spoken English and recorded all the basic monitoring information. It is expected that similar records would have been made by staff at Bolton at Home but the STeP documents are missing.
4.4.2 It has already been noted in paragraph 4.1.11 that Children’s Centres provided by Children’s Services are a universal service which is non-intrusive. However the records were not sufficient to give basic factual information which would demonstrate how well it was reaching out to isolated communities.
4.4.3 Attention was given by most agencies to language, with either records that both adults communicated well in English, or in a couple of cases more specific support before making the judgement. Staff Nurse 1 used an interpreter in Urdu when she wanted to ensure more complex information was understood, but following that visit it was noted the service was not needed again.
4.4.4 The Children’s Centre provided ESOL classes, but because of the emphasis on people attending when they wished Adult’s 1 attendance at only one class was not questioned. It may have been that she appreciated her English was of a good standard.
4.4.5 There is evidence that agencies considered culture more widely than just language. However one element of this may have been the health visiting and midwifery services interpreting Adult 2 being absent on many visits as him taking a ‘traditional role’ in parenting, rather than checking more about the impact of his learning difficulty on his role in the family.
4.4.6 Hospital 3 however had clear records of understanding the wider cultural needs with discussions about funeral arrangements, accepting the role of the wider family and also some use of Hindi, when a consultant was able to do so.
4.4.7 It has been noted in paragraph 4.1.5 that NWAS did not use Language Line, but it could have been inappropriate given the critical circumstances and with Adult 1 able to understand sufficiently. Hospital 3 had been told by Adult 1 and separately by Adult 4 that Adult 2 had a learning difficulty, and so ensured that all communication was in simple terms and that he understood.
4.4.8 Although the Area 4 records indicate some learning difficulty, the GP found no difficulty in communication with Adult 2 either because of learning difficulty or language. Bolton NHS FT has included a recommendation that includes ensuring staff have wider understanding of identity within the cultural and ethnicity context. This recommendation is endorsed by the NHS Bolton Commissioning Report.
4.5 What opportunities did the agency/service provide to Adult 1 and Adult 2 to speak independently of one and other about any concerns or worries they had prior to the birth of Child 1? On reflection can you identify any learning points?
4.5.1 Few agencies had opportunities to see either Adult 1 or Adult 2 alone and Bolton at Home notes in the IMR that as a housing agency, staff do not try to do so.
4.5.2 Children’s Services only saw Adult 1, but always in activity groups when the opportunity for staff to speak alone to any adult would have been limited. The Children’s Centre had recorded Adult 1 as an Urdu speaker, and possibly did not appreciate the standard of her English. Only the administrative staff member spoke Urdu, and the IMR suggests that Adult 1 spoke in Urdu to other parents.
4.5.3 The NHS records show that when Adult 1 was in a situation when she could speak freely (GP1, Midwife 1, Health Visitor 2 and at Hospital 3), she did reveal her concerns about Adult 2, Adults 3 and 4, and her feeling of loneliness. However when asked as part of the health visiting initial assessment, Adult 1 had said she had no concerns about personal safety or domestic abuse. If the GP record had been appropriately coded other practice based staff would have known of the history of domestic abuse. Also if the GP had notified the health visitor of the information it is possible Health Visitors 1 and 2 would have asked further questions when Adult 1 knew them better. Adult 1 had spoken to Staff Nurse 1 about financial concerns as well as the plan to separate, but had not spoken of any concern about having a second child.
4.6 To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family? What was the response of the agency and how did this feature in assessments, planning and interventions?
4.6.1 Community Housing Services were the first agency to have contact with Adult 1 and Adult 2. They were accompanied to their appointments by Adult 5, who confirmed the account of abuse they had experienced from Adult 4. It is expected that Bolton at Home also had this information. Both agencies did not consider the family to be at risk as they had taken steps to come to live in Bolton. This information was also held in a brief note in the GP records.
4.6.2 In addition, Adult 1 had told Staff Nurse 1 that Adult 4 was claiming Adult 2’s benefits. Staff Nurse 1 recognized this as a concern and although not constituting physical violence was evidence of controlling and intimidating behavior of wider family members. Adult 1 told Midwife 1 that the family had moved to get away from Adult 4 and the staff member understood the family was not in contact with the extended family in Area 4, but had support from an uncle (Adult 6) in Bolton.
4.6.3 Adult 2 gave Health Visitor 2 the same information some days later, but the record says the abuse was when he was a child. When the family was at Hospital 3, staff there recorded the historical abuse and respected the wish of Adults 1 and 2 that they only speak to Adults 3 and 4 with their permission.
4.6.4 In relation to abuse within the nuclear family, Adult 1 was asked about this directly on 2 occasions but she denied that there was any. As indicated previously, if the GP record had been known, Health Visitor 2 may have asked this question in a different manner, and received a different reply.
4.6.5 The midwifery notes also indicate that questions were asked about emotional well-being which include prompts about personal safety and relationships during the ante-natal period. No concerns were reported by Adult 1 at that time.
4.6.6 When Adult 1 spoke to Staff Nurse 1 about the plan for separation, Adult 1 was clear that the plan to separate was mutual and amicable.
4.6.7 The last time Health Visitor 2 saw Adult 1 and 2 together they were described as ‘being relaxed with each other and there was not an awkward or uncomfortable atmosphere. Adult 1 was not seen to be intimidated by Adult 2 and appeared to make decisions about the family.’
4.6.8 Health staff interviewed stated they are aware of domestic abuse issues and how they impact on children and high risk factors, but they did not detect any high risk factors for Adult 1.
4.7 On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work?
4.7.1 Housing agencies in Bolton are fully included in the arrangements for CAF, but in all their contacts found the family did not appear to need more support than that offered by Adults 5 and 6. Adult 2 has additionally reported good relationships with neighbours.
4.7.2 Community NHS staff completed detailed assessments when the family moved into Bolton, and after the birth of Child 1. However these staff did not have the benefit of the information given by Adult 1 to the GP. It is possible/probable that when Adult 1 and 2 began to disclose some details to Staff Nurse 1 and then to Midwife 1 an earlier referral would have been made for support from MARP. With information on the abuse in Area 4, Adult 1’s loneliness, and her not wanting a second pregnancy, the health visitor would have understood that Adult 1 has some long standing concerns, and was missing her family and the support they would offer.
4.7.3 Communication between health visiting and midwifery services was good, and the services although child focussed, included discussions on other family matters. Health Visitor 2 on reflection, without the information from the GP, considered she could have completed a CAF just before Child 1’s birth. Midwife 8 did make a referral, but using the single agency form, when with the additional information a CAF may have been more appropriate to access family support. This view is supported in the NHS Bolton Commissioning Report.
4.7.4 The Children’s Services IMR notes that the services should have insisted on a CAF because when the midwife sent in the referral, the family was known to health visitors, Children’s Centre, speech therapy, and the STeP housing programme. In this instance the referral could have led to a more robust response. Completion of the CAF process would have included the historical information from Area 4 giving a full picture of the family situation.
4.7.5 This point was discussed in panel, but panel members who are familiar with CAF thresholds considered that with all the information, and with hindsight, meeting the criteria for CAF was borderline.
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