Microsoft word - baby d exec summary 2004.doc

D was born on 7.10.03 the fourth child of his mother and the third child of her relationship with his father, the couple were separated at the time of D’s death. Their relationship was characterised by domestic violence with several of those incidents being referred to the Police and Social Services. At the time of D’s birth his father was bailed with a condition not to approach his mother, having been charged with a Section 47 assault against her. He met with his Probation Officer 14.10.03 and expressed concern about the welfare of the children and their mother’s capacity to care for them and that she may be depressed and drinking alcohol to excess during the evenings, this was referred to Social Services. Subsequent enquiries undertaken by Social Services resulted in a decision to close the referral on 27.10.03 On 5.11.03 the evening before D’s death his mother and the four children spent the evening at home and in the locality together mother’s friend. They watched fireworks in the garden and at a local pub then brought six cans of lager at an off license before returning home. On returning home the children were put to bed, two in their own beds, the oldest child in mother’s double bed. D was left wrapped up asleep in the living room while mother and her friend stood by the front door drinking lager and some sparkling wine. Sometime around midnight mother went to bed taking D upstairs with her. He did not settle in his Moses Basket so she took him into bed with herself and the oldest child, placing D on her chest. D did not apparently wake during the night to be fed. Sometime later mother awoke and found D lifeless next to her. She called an ambulance and D was taken to Hospital. Attempts to resuscitate him were unsuccessful and he was pronounced dead at 8.43 am. The Coroner was informed and on 7.11.03 a post-mortem examination was carried out. The inquest has yet to be held. Police Officers identified some empty cans of lager plus some other alcohol, together with “Prozac” medication in the house. Merseyside Police commenced an investigation which, ultimately, resulted in a decision to take no further action this decision was made on 13/12/04. There has been some debate throughout the work of the review group about whether this case met the criteria for a Serious Case Review. When the Serious Review Group was established there was concern that D had ingested Diazepam which significantly influenced the decision. It was not until a later date that further testing showed that this was a false toxicology result. Other features of the case do not fulfil the criteria for a Serious Case Review and could have been reviewed with internal management reviews. 2. • To review multi-agency involvement with D and his family, commencing with initial Domestic Violence referral to the police. • To complete an integrated factual chronology of agency contacts and • To review agency management reports and any additional documentation, and to assess whether actions taken have been congruent with individual agency procedures, ACPC procedures and best practice. • To recommend appropriate actions in respect of any single or multi- agency issues arising and including time scales for implementation of monitoring. • To present the final report and recommendations to an independent person for scrutiny and to the ACPC for endorsement.

3. Membership of ORG
The Overview Review Group consisted of representatives of the following
St Helens Social Services Department
St Helens Primary Care Trust
Merseyside Police
St Helens Education and Leisure Services
National Probation Service
4. Background Information
D’s mother was known to the police as a victim of Domestic Violence. This was
also known to the school attended by her oldest child. She presented as seeming
to care well for her children, she had experienced postnatal depression several
times in the past and had some involvement with psychiatric services but no
indication of negative thoughts of harming the children. The GP had some
knowledge of her alcohol usage but had no significant discussion with her about
this matter. D’s mother was on antidepressant medication throughout the period
covered by the chronology April 1999 to November 2003.
D’s father was known to the police as an offender and for Domestic Violence
incidents. He was subject to a Community Rehabilitation Order.
The family’s contact with Health Services did not identify any concern other than
some missed appointments.
D’s brother attended nursery and school no concerns were identified about him.
Staff did however note concerns for his mother around Domestic Violence issues
and offered support.
In Jan 2003 the NSPCC project received a Health Visitor referral requesting
support in helping D’s mother apply strategies to help her cope with the children’s
behaviour. She was visited by workers but failed to engage with the service
despite several attempts to visit.
Social Services received information about Domestic Violence incidents, advice
was given about available support, the case was then closed on each occasion.
5. Agency Involvement
Compliance with child health monitoring was reduced with the birth of each child.
Health records make no reference to issues of domestic violence or alcohol until
23.10.04. The Health Visitor at the time of D’s death had not identified any
concerns regarding alcohol. There is no record that she was made aware of any
domestic violence concerns
The involvement of NSPCC January – March 2003 was unsuccessful as D’s
mother did not engage with the services offered. No contact was made by the
project with the school or any other professionals because the difficulties in
engaging meant that the usual assessment process for the referral did not take
place. The voluntary nature of the project meant that contact with other agencies
would not be made without the consent of the service user unless child protection
issues were involved, and her consent was not obtained. There was a lack of
recorded information on the file about identified concerns.
Education staff had no concerns regarding the oldest child’s safety or welfare
during this period and they maintained good levels of monitoring in relation to his
progress and well-being.
At the time of D’s death his father was subject to a Community Rehabilitation
Order. During a routine appointment with his probation officer he discussed his
concerns about D’s mother’s use of alcohol and her capacity to care for D and
the other children.
His Probation Officer referred the concerns expressed by D’s father; there was
liaison with other agencies after which Social Services closed the case. There
was an expectation that further monitoring would be carried out by the Health
Visitor who had a visit planned.
The Police attended incidents of domestic violence on seven occasions between
May 2001 and February 2003; five of the incidents were also referred to Social
Services. The officer attending the scene of the violent domestic incident on
25.3.02 did not take positive action in line with the Merseyside Police Policy on
Domestic Violence. There was evidence of an assault and an arrest should have
been made. Information was not passed to the Police family Support Unit about
breach of bail conditions.
The Social Services casework file contained information about four of the five
domestic violence incident referrals noted on Police records but not about the
incident on 25.3.02 which was clearly an incident of significant concern. This
was later traced elsewhere in the Social Services filing system. However, it had
not been collated with the main family casework records. Given this it is difficult
to identify the extent to which the information was considered in context at the
time. Following the referral on 14.10.03 the case was allocated appropriately for
screening. However there was a delay in this process due to internal issues of
staffing and capacity. There was a failed attempt to contact the GP and the
records do not contain an exploration of the possible effects of depression and
prescribed medication and concerns about alcohol use. No checks were made
with the relevant school. There was a lack of clarity about the monitoring
arrangements made with Social Worker and Health Visitor
D’s mother was not made aware at any stage of the referral by any professional.

Key information was not shared concerning all the instances of Domestic
Violence. The Police failed to share a significant incident. The NSPCC did not
record concerns about Domestic Violence so this did not form part of the
assessment. Social Services did not share information about Domestic Violence
with the health Visitor on 23.10.03 when requesting information and support for
the family and health records make no reference to issues of domestic violence
or alcohol until 23.10.04.
There was a lack of clarity between Health, SSD and NSPCC about the levels of
concern and information sharing was based was based only on verbal
Within Social Services there were resource issues. The management of the
Assessment Team was under pressure due to holiday cover, the two managers
were unable to pass information directly to one another and made assumptions
about work having been completed as instructed. There was also only one senior
practitioner post
There were no breaches of the ACPC Child Protection Procedures The sharing of information by the Probation Service was appropriate and complied with local and national guidance. In their respective reports, where relevant, agency internal management reviews have identified recommendations which are endorsed by the Overview Review Group. The Overview Review Group has made the following recommendations: - 1 Professionals need to ensure they pass information on in a way that is clearly understood. A clear record should be made. 2 When there are concerns about a child all professionals known to be involved with the family should be consulted. The concerns about the child and family should be shared in full. 3 Where there is an expectation that monitoring is appropriate this will be explicitly agreed between the agencies, including identifying what is meant by monitoring and how feedback should be managed. The agreement should be recorded and confirmed in writing by each professional. 4 Professionals should not underestimate the effects of Domestic Violence. Procedures for decisions about when to conduct a Serious Case Review should be reviewed.

Professionals were offering support to the family and although there were some communication difficulties this did not significantly affect any outcomes. No cause of death has been defined for D. The inquest has yet to take place but no action is planned against any individual including his mother. The review was started a year ago and has been delayed due the unavoidable long-term absence of the Chairperson of the Overview Review Group. During this year there have been changes in practice which address some of the issues raised in the report.


Microsoft word - 3e4142d4-068a-083aab.doc

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