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Serious case review

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4.8. On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm or other missed opportunities to safeguard this child? Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this.
4.8.1 The housing agencies only had contact with the family prior to Child 1’s birth, but both confirm they had no concerns from their observations of the care given to Child 2. Additionally the family had recognised the negative impact of abuse and fled to protect themselves and their child.
4.8.2 Children’s Services Children’s Centres also only saw Adult 1 prior to Child 1’s birth. The staff had no concerns about the safety of a child cared for by Adult 1 from her presentation at the Children’s Centres.
4.8.3 In the GP IMR, the author interviewed the doctors and ANP who saw Child 1. They conclude that there was nothing to indicate that Child 1 was at risk of significant harm. These staff also would not know of the information recorded by the previous GP about Adult 2 hitting Adult 1, or the abuse from Adult 4, as the records had not been coded to draw attention to it. Even with this information the panel agreed that there was no evidence of significant harm to either Child 1 or 2.
4.8.4 The community health records are detailed and were used to apply the Significant Harm checklist. The chronology indicates a family who asked for appropriate services and who responded to the planned care for Child 2. The records also show that the staff informed each other as new information was given particularly by Adult 1, and that a wider picture was building up.
4.8.5 However the Bolton NHS FT IMR also highlights two points. The first is that even though full assessments were completed these were focussed and did not explore how Adult 2’s learning difficulty could impact both on his parenting and Adult 1’s feeling of isolation. In the absence of usual risk factors of substance misuse, mental health issues and domestic abuse only known of in the wider family, the learning difficulty of Adult 2 did not appear to be a significant risk factor. These comments lead to a recommendation in the NHS Bolton Commissioning Report that frontline NHS community staff and their managers who provide supervision should have improved awareness of how additional stressors can have an impact on young parents, especially when one parent has a learning difficulty.
4.8.6 The second point is that assumptions may have been made about Child 1 as this was not a first baby. However no one has recorded any assessment of how much care was provided by the extended family in Area 4, and then Adults 5 and 6 in Bolton. This information may have been significant in understanding any pressures for Adults 1 and 2 caring for two children independently.
4.8.7 However on the positive side, there was no evidence of previous injuries to either child, and the parents were seen to interact appropriately and with emotional warmth to the children. While the parents were receiving support from an increasing number of agencies, there was no evidence to suggest risk of significant harm.
4.8.8 This TOR is targeted to Child 1, but the IMR from Hospital 3 has raised an important issue for children’s services and the police where there is a life threatening illness and one or more other children in the family. All LSCBs have Sudden Unexplained Death of a Child/Infant (SUDC or SUDI). However there are no shared protocols for similar action when a child might have a serious or acute life threatening event but not die.
4.8.9 Hospital 3 has developed a protocol that has been accepted by all the Area 5 local authority LSCBs. This is known as Acute Life Threatening Event (ALTE), and is set out within the SUDI protocol, the difference being that in the instance of an infant death, the matters are within the remit of the Coroner.
4.8.10 The definition used to initiate ALTE is:-
Any sudden/unexpected collapse of an infant requiring some form of active intervention/resuscitation and subsequent intensive care/ high dependency unit admission and [the collapse] remains unexplained.’
The protocol expects hospital staff to notify the local Children’s Services for any child where the injury is either suspicious or unexplained. The early notification is to allow local procedures to follow through with checks of other children in the family and notification to the police should there be a need to secure the scene of a potential crime.
4.8.11 When Hospital 3 notified Bolton Children’s Services it was with the expectations in that the actions in paragraph 4.8.8 would be carried out. However in the absence of such a procedure in Greater Manchester, the accepted practice in Bolton is only to take any action when it has been confirmed that there is evidence of NAI. In fact the pro-forma does not assign specific tasks to be completed, but lists collection of contact telephone numbers and if the agency is included in the discussion. This SCR has identified that the pro-forma if adopted should be amended to provide clarity.
4.8.12 Discussion in the SCR panel confirmed that there had been a genuine misunderstanding, with Bolton Children’s Services accepting the information as an early alert to a child death with no apparent suspicious circumstances. However this delayed and confused the welfare check on Child 2, and delayed notification to the police. This second delay was further exacerbated by NWAS not notifying the police of the emergency call as is expected. The Bolton NHS FT IMR recommends Hospital 1 A&E department should check that a police notification has been made.
4.8.13 When Bolton Children’s Services were notified later in the day of the retinal haemorrhage, the senior manager made the decision to wait until the morning to notify the police of developments. However this decision was made with the expectation that NWAS would already have notified the police of the circumstances of the admission to Hospital 1.
4.8.14 The panel agreed that wider acceptance of the ALTE protocol would be beneficial for all LSCBs where infants could be admitted to Hospital 3 and also to Hospital 2. It is included as a recommendation of the NHS Bolton Commissioning Report as well as within the Hospital 3 report. Additionally the NHS Bolton Commissioning Report recommends introducing a similar protocol for children who remain in Bolton for investigation and treatment.

5. Summary
5.1 the narrative on each IMR and the responses to the Terms of Reference indicate that agencies worked competently, mainly meeting expected standards of practice and with an understanding and respect for the cultural identity of the family. The records also describe a young couple who showed maturity, ability to manage the household, and a warm and caring approach to parenting.
5.2 The main service providers were staff from NHS services provided universally, but with increased support and specialist services when assessments demonstrated the need. The Ofsted Biennial review referred to in paragraph 4.2.6 also notes: Almost half of 189 children were under one year of age and a third were very young babies under 3 months. This repeats the findings of the last biennial analysis and reinforces the importance of the safeguarding role for health staff (especially midwives and health visitors) working with young babies and their families, as noted by Lord Laming (2009).

Progressive universalism,’ offers a more targeted health visiting service to families assessed as having a higher level of need. But if this need is not identified in the antenatal period, or soon after, the children will not get access to this additional support and monitoring by health professionals. It is the view of the panel that NHS community staff provided this service.

5.3 When Adult 1 used services at the Children’s Centres she was able to meet with other parents who spoke Urdu. Her attendance with Child 2 was not consistent, but the reason for this is not known.
5.4 Housing services provided a prompt assessment of need, recognised when the family’s needs became more urgent and as part of the STeP programme provided more support to maintain the tenancy because of their young age.
5.5 When Child 1 was in cardiac arrest, emergency services and both hospitals provided prompt, specialist, and sensitive care.
5.6 The IMRs identify some occasions of poor or missed communication, (specifically the GP not passing on information from Adult 1, the health visitor not considering a CAF, transfer between the teams in NWTS, NWAS not notifying the police of the unexplained cardiac arrest and the misunderstanding between Hospital 3 and Bolton Children’s Services), but on the whole communication within and between services was good, and recorded in detail.
5.7 The key area where, with hindsight, agencies acknowledge a better service could have been provided is understanding the context of the capacity to parent. Assessments did not complete the picture of Adult 1 needing more personal support and her possible acceptance of domestic abuse and Adult 2 possibly needing more direct input to help him to parent because of his learning difficulty. Equally, except for housing agencies, it was not known for some time that the family had fled from abuse within the extended family.
5.8 Panel had discussion about the level of need demonstrated when information from all agencies was combined into the chronology and IMRs. As the NHS Commissioning Health report notes the service did not offer Adult 1 information and guidance on the opportunities to get more support from within the community.
5.9 However panel agreed that even with the information combined the family needs did not meet the threshold for formal co-ordination of multi-agency working using the CAF and Child Action Meeting process as detailed in Bolton’s Framework for Action.
5.10 It is within this context that the panel concluded that the death of Child 1 was neither predictable nor preventable. In fact, the Panel acknowledged the challenges all workers face when assessing risk, managing resources and getting the right balance between support and the need to respect private family life. This case has highlighted this, particularly as this family generally offered a good standard of care and were responsive to their children’s needs.

  1. Lessons learned from this SCR

6.1 each agency has identified individual recommendations, mainly linked with improving records or direct communication. The panel considered that apart from these the recommendations led to three main areas of learning from the SCR. They are:-

    1. Recognition of the importance of domestic abuse, however low key the disclosure appears to be, when there are children in the household. The GP did not liaise with the health visitor about Adult 1’s disclosure of domestic abuse, nor did he code that disclosure on her records so that it would be seen immediately if there were further disclosures. With this information, when Adult 1 was asked about her safety, the question could have been phrased acknowledging a history of abuse, making it easier for her to disclose any further concerns. It is possible that Adult 1 would have disclosed information about the family in Area 4 much sooner, giving a clearer picture of her life.

    1. Recognition of the stressors contributing to the vulnerabilities of Adult 1 and Adult 2. There was only partial recognition of Adult 1’s vulnerabilities in relation to a number of circumstances: her arranged marriage; her suggestion that the pregnancy was not wanted by her; her husband’s learning difficulties; her abusive and controlling father-in-law; her isolation after leaving Area 4; financial issues; her immigration status and her need for support from her own family in Area 3.

    1. Also Adult 2’s learning difficulties were not understood or fully explored. Agencies provided services based on their expectation that Adult 2 was the head of the household, in a traditional cultural model when in fact Adult 1 was in control. If staff had employed a more challenging assessment of family functioning, these elements may have been known earlier. Some understanding of Adult 2’s limitations caused by his learning difficulties would have completed the picture of Adult 1’s situation.

    1. With all the information now gathered about the two adults, it is accepted that it would have been appropriate for a CAF to be made, so that all options to support the family could have been considered between all the agencies.

    1. Use of ALTE protocols. On the day the child presented at hospital, there was a sequence of not notifying the police of the unexplained cardiac arrest of Child 1. It is expected that the person taking the call at NWAS headquarters will notify. This was not done, and on arrival at Hospital 1 there was no check that it had been done. The ALTE protocol in use at Hospital 3 intends that when a child has a life threatening illness or injury the local children’s services are notified, who should in turn notify the police. This pro-forma should be explicit about who has specific responsibilities for each action.

    1. Bolton Children’s Services were notified of Child 1’s admission to Hospital 3 and that Child 1 was unlikely to live. Initially it was notification only. After there was a possibility that this cardiac arrest was unexplained a further notification was made. The expectation at Hospital 3 was that Children’s Services would notify the police. The ALTE protocol is in place to ensure that all agencies are alert to the possibility of beginning procedures linked with safeguarding.

    1. These three areas of learning are reflected in the recommendations in the NHS Bolton Commissioning Report and the GP IMR. The recommendation on adopting the ALTE pro-forma at Hospital 1 would ensure clarity on who should make the appropriate notifications. The SCR panel has fully discussed the individual agency and NHS Bolton Commissioning report recommendations and fully endorses them all. The panel has no further recommendations.

7. Recommendations
7.1 Summary of IMR Recommendations

  • This review has found a good standard of practice in all agencies. The family were provided with a range of universal services that met their needs, taking account of their culture and language. Within the NHS in particular the agencies can be proud of the quality of service provided as a routine and at the time of the emergency. However, as always when services are examined in detail, there is learning leading to some recommendations to improve practice or develop services further.

  • Bolton Safeguarding Children Board will request and require all agencies who contributed to this SCR to provide six monthly progress on the implementation of their action plans until all elements have been completed.

7.2 Summary of IMR Recommendations

Hospital 3 recommended that:-

  • Record keeping issues highlighted within the addendum report shall be used as a basis for learning with both the health professionals directly involved in the care of the child and as part of the mandatory safeguarding training provided to all health professionals across the organisation

  • Health Overview Author makes a recommendation to the Northern Strategic Health Authority to request all LSCB’s across the region review and amend their current SUDI/SUDC protocol to include guidance on the management of a child suffering an ALTE, which would include triggering a referral to Children’s Services and the Police

Bolton at Home recommended that:-

  • Introduces electronic storage of STeP assessments

Bolton NHS Foundation Trust recommended that:-

  • All services have up to date knowledge and skills about domestic abuse

  • Awareness is raised with relevant staff about the CAF process specifically when to initiate CAF and develop CAF skills

  • Children’s identity issues are explored when health services are provided

  • Assessment and recording in relation to attachment is further developed

  • Consider implications of research and practice developments in other areas for keeping infants safe

  • Remind relevant Foundation Trust staff of the Sudden Unexpected Death of Children process in relation to ensuring that contact has been made with the police

  • Increase awareness of the vulnerability of infants to include all services in community and acute setting

Children’s Services recommended that:-

  • To ensure the registration forms in the Children Centres are fully completed at the time of registration. To check details are up to date on the registration form if families present at a different centre

  • Consider a general overview recording of each session and to think about how learning can be transferred into the home

  • Review the referral process to the MARP

Community Housing Services recommended that:-

  • Case record/Visit forms should be amended to indicate all individuals present during contacts

GP recommended that:-

  • Promote as good practice referring cases of domestic abuse to Health Visitors where preschool children are in the family and code the domestic abuse in the records

  • Promote as good practice stripping off babies fully for examination by GPs

North West & North Wales Paediatric Transport Service (NWTS) recommended that:-

  • Ambulance staff to undertake safeguarding training

North West Ambulance Service (NWAS) recommended that:-

  • NWAS Safeguarding Children Policies and Procedures are strengthened in relation to taking into account issues of ethnicity, diversity, culture and language which may pose barriers. Current policy and procedures due to be updated

  • Specific reference to ‘language- line’ will be added into the policy and procedures to ensure staff can communicate effectively with patients and relevant others

  • Update the Sudden Untoward Death of Children Procedures to ensure that during any Acute Life Threatening Event (ALTE) or sudden untoward death of a child, the police must be notified by the relevant Emergency Control Centre Call Taker

7.3 Summary of PCT Commissioning Health Overview Report

The PCT Commissioning Health Overview Report recommended that:-

  • Greater Manchester LSCBs and NHS Greater Manchester to amend the current Protocol “Sudden Unexpected Deaths in Childhood” to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE). This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis

  • Bolton Foundation Trust to consider adopting the ALTE pro-forma for use in children who remain in Bolton for their investigation and treatment. This should specify explicitly who will be contacting each agency involved and when this has been done so that there is no delay in involvement of any individual agency

  • Hospital 3 to review the ALTE pro-forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed

  • Raise awareness of the impact of additional stressors including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties. This recommendation relates to frontline health workers responsible for assessing children and families’ needs and also managers responsible for clinical supervision

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