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Serious case review

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In Respect Of
Child 1

Overview report prepared by:-

Hester Ormiston, Independent Author


Overview Report Endorsed by:-
Mike Tarver, Independent Chair, BSCB


1. Introduction:

1.1 Circumstances that led to the Review Page 3

1.2 Terms of Reference Page 4

1.3 Timescale for the Review Page 5

1.4 Panel Membership Page 5

1.5 Individual Management Reviews & Page 6

Additional Information

1.6 Involvement of other LSCBs Page 7

1.7 Family Composition Page 8

1.8 Genogram Page 9

1.9 Family Involvement Page 10

1.10 Issues of Race, Language, Culture, Religion Page 11

and Disability

1.11 Media Interest Page 11
2. Overview of what was known Page 11
3. The Individual Management Reviews (IMRs) Page 12
4. Conclusions and Analysis Page 33
5. Summary Page 44
6. Lessons Learned from this SCR Page 46
7. Recommendations:

7.1 Summary of SCR Recommendations Page 47

7.2 Summary of IMR Recommendations Page 47

7.3 Summary of PCT Commissioning Page 49

Health Overview Report

  1. Introduction

1.1 Circumstances that led to the Review
1.1.1 Child 1 was taken to the GP’s surgery by the father, Adult 2 as the child appeared unwell. The advanced nurse practitioner at the practice examined the child, gave advice and the family returned home. Once at home, while the mother (Adult 1) was upstairs with Child 2, Adult 2 made himself a drink in the kitchen. He heard Child 1 crying. When Adult 1 came downstairs she found Child 1 appeared to have stopped breathing and was floppy. She ran with the child into the road and a neighbour, who was in the road at the time, rang for an ambulance. Child 1 was taken by the neighbour back into the family home, Address 4 where he started CPR. Child 1 was taken with Adult 1 to Hospital 1. The child was, later that evening, transferred to Hospital 3 and supported by a life support machine but reported to be unresponsive.
1.1.2 The following evening Child 1 was reviewed by an eye specialist who identified evidence of retinal bleeding. At that stage it could not be confirmed whether it was a consequence of medical intervention or non-accidental injury. Child 1 died shortly after 9 pm.
1.1.3 A post mortem was conducted and revealed a 4 x 5 cm bruise under the skin on the right hand side of Child 1’s skull. Under this was a 4 cm linear fracture of the skull. The brain had haemorrhaged to both sides and blood was evident in both optic nerves. There were also calcified nodes on the third and fourth ribs at Child 1’s spine on the left hand side. These appeared to be old injuries but it was not known whether or not they were due to non-accidental injury.
1.1.4 The provisional post-mortem findings suggested that Child 1 suffered a fatal traumatic head injury which could not have occurred without some force being applied to an immobile baby. Neither parent had an adequate explanation for the injuries.
1.1.5 The information in paragraphs 1.1.1 to 1.1.4 was notified to the independent chair of Bolton Safeguarding Children Board who considered that the circumstances of Child 1’s death were likely to meet the criteria set out in the first part of Working Together to Safeguard Children 2010, namely:-
When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family.
1.1.6 Ofsted was notified of the details of Child 1 and that a Serious Case Review (SCR) may be held. An Initial SCR Panel was convened and the information shared at that meeting did suggest that Child 1 died as a consequence of suspected non-accidental injury. This recommendation was endorsed by the Independent Chair of BSCB and this was shared with Ofsted in writing.
1.2 Terms of Reference (ToR)

      1. Initial agency reports had been prepared by:-

  • Greater Manchester Police

  • Bolton NHS Foundation Trust

  • General Practitioner, NHS Bolton

  • Bolton Children’s Services Staying Safe

  • Bolton Children’s Services, Children and Families Support Service (Children’s Centres)

  • Bolton Council, Community Housing Services

  • Bolton at Home

1.2.2 Using the information available from these reports, the Panel agreed the following questions were appropriate as key lines of enquiry in agency individual management reviews (IMRs).

  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

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

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. To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues?
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?
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?
7. On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work?
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.

    1. Timescale for the Review

1.3.1 The timescale for the review was agreed from the point the family moved to Bolton until the outcome of the post-mortem.

1.4 Panel Membership
1.4.1 The SCR Panel comprised:-

  • Vlasta Novak, Independent Chair

  • Hester Ormiston, Independent Report Author

  • Assistant Director, Bolton Children’s Services

  • Detective Inspector, Serious Case Review Team, Greater Manchester Police

  • Bolton Council of Mosques

  • District Manager, Bolton Children’s Services

  • Associate Director Safeguarding (Designated Nurse), Bolton PCT

  • Consultant Paediatrician, Designated Doctor for Safeguarding, Bolton PCT

  • Head of Personalisation & Inclusion, Adult Community Services

  • Housing Options and Advice Services Group Manager, Bolton Council Community Housing Services

The Panel was supported by:-

  • Safeguarding Board Officer (Advisor)

  • Senior Administrator, Safeguarding Children Board (Minute Taker)

  • Solicitors from Legal Services, Bolton Council

The Panel met on five occasions on.

The Overview Report was presented and endorsed by BSCB within the required six month timescale.
1.4.2 IMR authors were invited to attend in turn on two occasions for discussion and feedback on each agency report. The NHS Overview report was discussed at a subsequent meeting.
1.5 Individual Management Reviews (IMRs) & Additional Information
1.5.1 The following agencies were asked to provide IMRs:-

  • Bolton NHS Foundation Trust (to include midwifery, health visiting and Hospital 1)

  • General Practitioner services

  • Bolton Council Community Housing Services

  • Bolton at Home

  • Children’s Services Staying Safe and Children’s Centres (combined report)

  • North West Ambulance Service,

  • North West Transport Service, and

  • NHS Commissioning Health report

1.5.2 All the IMRs have been prepared by staff or managers who have not had direct or line management contact with the family prior to the death of Child 1. Each one has been countersigned by heads of service or equivalent. The panel has considered each IMR, in conversation with the author, offered comments and following some revisions found that they meet the expectations of Working Together 2010. One IMR is in a different format but provides all the necessary information and analysis to contribute to the overview report.

1.5.3 BSCB procedures include an expectation that all IMRs will be closely scrutinised, and if not of sufficient quality will be returned for ‘revision’ to the agency. This process has been followed by each agency and the reports have been completed to a high standard in written styles which are clear and informative.
1.5.4 In addition to IMRs the SCR Panel requested information from:-

  • Greater Manchester Police

  • Bolton Council Adult Services

  • Bolton Legal Services

  • Hospital 3 NHS Foundation Trust

These services were asked to provide a letter or report to outline any involvement with the child or their family.

1.5.5 As there was a possibility that the immigration status of Child 1’s mother, Adult 1, could have had some impact on family relationships the United Kingdom Border Agency (UKBA) was asked for any relevant information on her stay in the UK.
1.6 Involvement of other LSCBs
1.6.1 Panel discussed that although the SCR should focus on Child 1’s life it would be useful to have background information from Area 4 where the family had lived prior to Child 1’s birth. In particular Area 4 services were asked to provide a summary of their knowledge in relation to:-

  • Adult 1’s immigration and marital status

  • Adult 2’s learning disability/difficulties assessments, service provided and outcome

  • Wider family relationships, tensions within these relationships and any domestic abuse issues

  • Opportunities for agency’s to observe parenting capacity and outcomes from these

  • Services offered and accessed by the family

  • Profile of BME communities in Area 4 and how this family functioned within the community or accessed support to meet any diversity needs

  • Any additional vulnerability issues identified by services in Area 4

This information was requested and submitted by Area 4 LSCB to the SCR Panel.

    1. Family Composition

Anonymised Name

Relationship to subject (if applicable)


Ethnicity or diversity issues

Child 1


Address 1

Pakistani/British Muslim

Child 2


Address 1

Pakistani/British Muslim

Adult 1


Address 1

Pakistani Muslim

Adult 2


Address 1

Pakistani/British Muslim

Adult 3

Paternal Grandmother

Address 2

Pakistani Muslim

Adult 4

Paternal Grandfather

Address 2

Pakistani Muslim

Adult 5

Paternal Aunt

Address 3

Pakistani/British Muslim

Adult 6

Maternal Uncle

Address 3

Pakistani/British Muslim

1.8 Genogram
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Adult 4

Paternal Grandfather

Not Known

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Adult 6

Maternal Uncle

Adult 2


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Child 1 Child 2


1.9 Family Involvement
1.9.1 The panel considered that it would be appropriate to ask Child 1’s parents, Adults 1 and 2, and the close family members living in Bolton if they wished to make any comment on the services provided across Bolton.
1.9.2 As it was important that any legal process should not be compromised, it was agreed that the independent SCR chair would write initially to Adults 1 and 2 via their solicitors to inform them of the SCR process. On police advice a list of questions was submitted to the Senior Investigating Officer who confirmed that they were unlikely to elicit responses which might compromise any criminal proceedings. These were sent with a further letter to the solicitors of Adults 1 and 2.
1.9.3 A letter was also sent to Adult 5 to invite her comments. Adult 5 contacted the Safeguarding Unit, asking to meet with a Panel representative and BSCB officer. The Panel Chair and BSCB Safeguarding Officer met with Adult 5.
1.9.4 Adult 5 considered that the services provided to the family had been good. She commented that perhaps more practical information could have been given to Adult 1, who may have found it more difficult living as a ‘single’ family; that is, not living with the extended family who would ordinarily provide care to any child in the household. Additionally Adult 5 noted that the service provided at Children’s Centres is good, but could provide more focussed support for parents while the children play together. It would also be useful if the service was specifically extended to fathers as well. It was agreed that further contact would be made with the family prior to publication.
1.9.5 Following endorsement by Bolton Safeguarding Children Board and in preparation for publication further engagement was undertaken with the family. Adult 1, Adult 2 and Adult 5 all had the opportunity to read the report in full before publication. In response to their feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that all dates, as well as gender references relating to the children would be removed from the report. It was agreed this did not detract from the learning.
1.9.6 Adult 1 also wished to state she disputes the record that she was not happy with the second pregnancy. She has reported that this was a planned pregnancy, she was happy about this but she was unhappy with the circumstances between her and Adult 2. In response to this feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that this would be noted in the report but this is what she is believed to have said at the time.
1.10 Issues of Race, Language, Culture, Religion and Disability
1.10.1 Adult 1’s immigration status was that she had leave to remain in the UK for a period. The family are Muslim with Adult 1 speaking both Urdu and Hindi. The marriage between Adults 1 and 2 took place in Area 3, possibly by Sharia law, with no UK civil marriage; Adult 2’s family live in Area 4. Adult 2 has been in receipt of some disability benefits because he has a learning difficulty.
1.11 Media interest
1.11.1 There was local and national media interest on the day Child 1’s parents were interviewed by the Police, following a Police press statement about a murder investigation. The Panel considered there was likely to be further significant media interest in the SCR and any enquiries would be dealt with jointly via the Council and Greater Manchester Police’s press offices.

  1. Overview of what was known

2.1 Background information provided by Area 4 Safeguarding Children Board indicates that Adult 2 lived with his extended family from birth in Area 4. As a child he had few health needs but details of his education are held in some health, education and Connexions records as from the age of twelve he attended a school for pupils with moderate learning difficulty. In particular Adult 2 was unable to read, write and communicate in line with his chronological age, and had poor concentration.

2.2 Both Adult 2 and his father, Adult 4, have a police record, each having one offence relating to motor vehicles; Adult 4 also has a conviction for Possession of a Controlled Drug and Adult 2 was interviewed for supplying a controlled drug.
2.3 Adult 2’s sister, Adult 5 also lived with the family, and her husband, Adult 6, joined them when they married. The records suggest that Adult 2 had another sister, as there is a note of her alleging rape when she was seventeen years old. Adult 6 was arrested and charged but the statement was withdrawn.
2.4 Adults 5 and 6 left the family home in Area 4 at some point that predates the Terms of Reference and moved to Bolton. They reported that they found Adult 4 intimidating and controlling.
2.5 Adult 1 had joined the extended family from Area 3 and Child 2 was born. Adults 1 and 2 moved to Bolton, asking for assistance from the police to collect their belongings and Child 2 from the family home. At the time Adult 1 reported that she was not allowed to contact her family in Area 3; later the couple told agencies in Bolton that Adult 2’s father used to hit him, as well as dictating what they could and could not do and managing their benefits, including Adult 2’s disability allowance.
2.6 When Adults 1 and 2 moved to Bolton they lived with Adults 5 and 6. Adult 5 provided them with support to apply for their own tenancy. They presented as homeless, accepting that immediate homelessness was not likely. However the couple presented a second time, as the lodging arrangements were no longer sustainable. A house was allocated, which the family moved into after refurbishment. As part of the housing application Bolton Community Housing Services checked the immigration status of Adult 1 and were told of her ‘limited’ leave to remain; they also confirmed via routine checks that Adult 2 was entitled to additional benefits because of his disability.
2.7 Child 1 was born eight months after Adults 1 and 2 moved with Child 2 into their furnished home rented from Bolton at Home. The tenancy was in Adult 2’s name only possibly as a consequence of Adult 1’s immigration status. As Adult 2 was aged under 25 years, the family had a Tenancy Action Plan as part of the Tenancy Sustainment Service. This meant the family had regular visits from a Support Officer.

3. Individual Management Reviews
3.1 bolton Community Housing Services
3.1.1 Community Housing Services provides a range of housing and access related services including management of the housing register and choice based lettings, homelessness and housing advice. It is the first agency any person seeking housing in Bolton would attend.
3.1.2 The IMR has been prepared by the Head of Community Housing and countersigned by the Chief Planning and Housing Officer. The author has an overview of all housing services that would have been relevant to the family.
3.1.3 The report uses information from case notes and staff interviews:-

  • Homelessness presentation case file

  • Homelessness presentation case

  • Homelessness prevention case file

  • In electronic records (OHMS, the Integrated Housing Management system). This system holds details of housing applications, allocations and rent accounts

  • Interviews with two staff members who provided the service to the family; one staff member has retired but had maintained detailed case notes

3.1.4 The front page of the report gives a brief profile of the agency responsibilities giving context to the rest of the report. The report includes responses to a number of standard questions for an IMR which are helpful, but leads to some repetition of information which specifically addresses the key lines of enquiry.

3.1.5 Community Housing Services had four direct contacts with Adults 1 and 2. Three were at the Housing Options Centre, where Adult 2 was helped to make an application for housing and when homelessness was imminent, documents were checked and a tenancy offered. The family was visited at Adult 5’s home to confirm the circumstances of the potential homelessness, and to clarify immigration status and any specific needs. Adult 2 was advised to attend the appointment to check he had the capacity to sign a tenancy agreement.
3.1.6 The involvement of Community Housing Services ended prior to the family’s move to their own tenancy and Child 1’s birth.
3.1.7 The service had limited opportunity to observe the family. However the records on the family’s presentation show how the agency systems, training and supervision support staff to record contacts in a manner that takes account of abuse both to children and adults, as well as consider any disability or cultural needs.
3.1.8 The IMR concludes that the service provided to Child 1’s family followed all procedures, in a ‘professional but attentive and caring manner’. There is one recommendation that in all contacts a record of all people present should be maintained.

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