Norfolk Safeguarding Children Board Serious Case Review

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Norfolk Safeguarding Children Board Serious Case Review

Transcript Of Norfolk Safeguarding Children Board Serious Case Review

Norfolk Safeguarding Children Board
Serious Case Review concerning AB1 & AB2
Overview Report
Lead Reviewer: Peter Ward Published: June 2019

Table of Contents
1. Introduction 2. The Review Process 3. AB1 – Family Circumstances and Key Practice Issues 4. AB2 – Family Circumstances and Key Practice Issues 5. Consideration of Key Research Questions 6. Learning from the Review 7. Recommendations

Page 3 3 5 11 15 39 42

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This Serious Case Review is a thematic review which concerns two

babies from two different families both of whom died when they were less

than two months old whilst sleeping with parents who were under the

influence of alcohol and other drugs. The circumstances leading up to the

deaths of the babies have been considered separately and individually but

one Serious Case Review Panel and one Lead Reviewer has undertaken

this work so that common themes can be identified and one set of

recommendations produced.


The Review Process


Chapter 4 of Working Together to Safeguard Children 20151, states that

Serious Case Reviews and other case reviews should be conducted in a

way which:

➢ Recognises the complex circumstances in which professionals

work together to safeguard children.

➢ Seeks to understand precisely who did what and the underlying

reasons that led individuals and organisations to act as they did.

➢ Seeks to understand practice from the viewpoint of the individuals

and organisations involved at the time rather than using hindsight.

➢ Is transparent about the way data is collected and analysed.

➢ Makes use of relevant research and case evidence to inform the



In order to meet these requirements this Serious Case Review has been

undertaken using a ‘systems approach’2, as recommended by Munro

(2011) and authorised within Chapter 4 of Working Together to Safeguard

Children 2015.


A Serious Case Review Panel with the following membership was

established to oversee the review:

➢ Head of Patient Safety and Safeguarding - Norfolk and Suffolk NHS

Foundation Trust

➢ Deputy Designated Nurse Safeguarding Children - Designated

Safeguarding Children Team (Norfolk & Waveney)

1 This Serious Case Review was commissioned before the publication, in 2018, of a revised version of Working Together to Safeguard Children. Consequently it has been conducted in line with the guidance contained within the 2015 version. 2 The systems approach “focuses on a deeper understanding of why professionals have acted in the way they have, so that any resulting changes are grounded in practice realities” (Munro, 2011). It “looks for causal explanations of error in all parts of the system not just within individuals” (Munro, 2005).

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➢ Detective Inspector – Norfolk Police ➢ Safeguarding Lead - Norfolk and Norwich University Hospital NHS
Foundation Trust ➢ Early Years Improvement and Inclusion Officer - Children's
Services ➢ Quality & Effectiveness Service - Children's Services ➢ Adviser – Safeguarding – Children’s Services ➢ Named Nurse for Safeguarding Children – Cambridgeshire
Community Services ➢ Tenancy services and Income Manager - Norwich City Council ➢ Group Business Improvement Advisor - Broadland Housing


The Review Panel decided that in respect of each child, the review should

consider a period of 12 months immediately preceding the death of the

child. In the case of AB1 this was a period up to November 2016 and in

the case of AB2 up to February 2017. Organisations which had been

involved with the family between these dates were asked to provide

chronologies of their involvement over this period including analysis of this

involvement. Organisations were also asked to provide relevant

background information which pre-dated this time period.


Information was provided by the following organisations:

➢ Norfolk and Suffolk NHS Foundation Trust

➢ Clinical Commissioning Group

➢ Norfolk Police

➢ Norfolk and Norwich University Hospital NHS Foundation Trust

➢ Social Care, Children's Services, Norfolk County Council

➢ Education, Children's Services, Norfolk County Council

➢ Early Years, Children's Services, Norfolk County Council

➢ Cambridgeshire Community Services

➢ Broadland Housing Association

➢ Clarion Housing Group

➢ Local District Council


Following receipt of the agency information the Review Panel identified six

Key Research Questions for the review to consider. These are addressed

in section 5 of this report.


Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015

lists seven “principles for learning and improvement” that should be

applied to all reviews. One of these is that “professionals must be

involved fully in reviews and invited to contribute their perspectives

without fear of being blamed for actions they took in good faith”. In

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3.1 3.1.1

carrying out this review the Lead Reviewer held ‘Learning Events’ in respect of each child, to which front staff and their managers were invited. This helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took. This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used.
Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”. Both parents of each child were invited to meet with the Lead Reviewer and the Board Manager of Norfolk Safeguarding Children Board. This invitation was accepted by the mother of AB1 and the father of AB2 and meetings duly took place. The maternal grandmother of AB1 was also present for the meeting with AB1’s mother and AB2’s social worker was present for with meeting him. These discussions helped the Lead Reviewer to gain a better understanding of the family’s situations at the time and how services were perceived by them. Information gathered during the meetings has been used to inform this report. The father of AB1 and mother of AB2 declined the invitation to contribute to this review. During the meeting with AB1’s mother the Lead Reviewer explored the possibility of meeting with AB1’s eldest sibling to enable her to contribute. The mother explained the difficulties her eldest daughter had experienced since AB1 died and expressed her opinion that a meeting might re-traumatise her. It was therefore agreed not to pursue such a meeting.
AB1 – Family Circumstances and Key Practice Issues
This section of the report provides brief information about the circumstances of AB1’s birth and death, his family circumstances and a factual summary of key areas of agency involvement with the family. It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed.

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3.3 3.3.1 3.3.2

In October 2016, AB1 was born in hospital at nearly 39 weeks gestation; there were no complications with his birth. He was born into a large, blended family with four full and half siblings, three of whom (Sibs1(1) – 3(1)) were at school and one of whom (Sib4(1)) was at pre-school. The family were living in an overcrowded two bedroom house rented from a housing association.
When AB1 was approximately one month old, his mother woke in the morning having fallen asleep on the sofa with him in her arms after giving him a night time feed. AB1 had apparently suffocated and tragically died whilst his mother slept. Both parents had been drinking the previous evening and had taken drugs. The mother admitted a charge of child neglect. The father, who had slept upstairs in bed that night, was not prosecuted.
Key Practice Issue 1 - Referral to Children’s Social Care and subsequent Child In Need Plan
In July 2015, 15 months before AB1 was born, the Police referred the family to Children’s Social Care when the mother suffered a drug induced psychosis and was unable to care for the children. There were concerns that the father could not provide safe and secure care due to his own use of alcohol and drugs.
A social work assessment was completed which highlighted parental drug misuse and the impact of this on the mother’s mental health and parenting capacity. It was identified that the mother had strong networks of support and that the father was supportive but there was a recommendation for Child In Need support to explore the longer-term pressures of mother’s mental health and substance misuse. A Child in Need plan was agreed and this remained in place throughout the period considered by this review with Child In Need meetings taking place approximately every month.
Specific action points on the Child in Need action plan during this period addressed the following issues that are relevant to this review:
➢ The mother to engage with relevant services to address mental health and substance misuse issues;
➢ The father to engage with relevant services to address substance misuse issues;
➢ Support to the family with seeking re-housing to a larger home;

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3.3.4 3.3.5 3.4

➢ The need for the father to be involved in caring for the children whilst the mother was recovering from her psychosis and regaining confidence.
As time moved on and the mother became pregnant additional action points were added to the plan relating to the needs of the baby.
The social worker had supervision with their manager one month after AB1 was born and it was agreed that consideration would be given to ending the Child in Need plan at the next Child in Need meeting with Children’s Social Care ending its involvement.
Key Practice Issue 2 - Mother’s substance misuse
In October 2015, the social worker referred the mother to the Norfolk Recovery Partnership3. Following an assessment she was allocated a drug worker and referred to the in-house counsellor and to the service psychiatrist for a review of her medication. Between November 2015 and April 2016, when the mother discovered that she was pregnant, the drug worker visited the home seven times and saw the mother on all but one occasion. Five appointments were made for the mother to attend an appointment away from the home and the mother attended one of these. Over the same period 12 counselling sessions were arranged and the mother attended five of these. On some occasions in sessions with the drug worker the mother admitted to use of alcohol and drugs, including cannabis, cocaine and quetiapine. On other occasions she denied any substance misuse.
After the mother found out that she was pregnant with AB1 she was present for seven of nine home visits with the drug worker and four out of 10 counselling sessions. The mother reports that she abstained from alcohol and drugs throughout the pregnancy. This cannot be confirmed but there is no evidence to dispute it. In mid September 2016, during a visit, the drug worker found the mother in a good mood because rent arrears had been paid off and they could now bid for a housing transfer. The mother agreed to think about discontinuing counselling in view of her pregnancy and missed appointments. Two weeks later the mother was not at home when the drug worker visited. The drug worker sent an email to the social worker stating that the mother had attended the majority of appointments and was substance free with little risk of relapse. Counselling had ceased and the mother was due to be discharged from the drugs service. The drug worker also phoned the mother to discharge

3 Drug and alcohol service provided under contract by Norfolk & Suffolk NHS Foundation Trust

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3.5.2 3.5.3
3.6 3.6.1

her from the service after the mother had cancelled two appointments in the first three weeks after AB1 was born.
Key Practice Issue 3 - Father’s substance misuse
The father had a drug worker from Norfolk Recovery Partnership prior to the Child in Need plan being agreed. This was due to him being subject to a community order having been convicted of shoplifting. When the order ended, in January 2016, he did not take up Norfolk Recovery Partnership’s offer of continued involvement and did not accept that alcohol misuse was a problem for him.
Information provided at Child in Need meetings and by the mother indicates that the father was drinking on a daily basis and would sometimes go to bed during the day after drinking.
The father self-referred to the drug and alcohol service in July 2016 reporting drinking more than 10 units daily and with a history of physical illness associated with alcohol misuse. He was allocated a drug worker, whom he saw twice in the first half of August 2016 but did not attend any further appointments.
Key Practice Issue 4 - Support with child care issues
In September 2015, a Family Support Worker from the Early Years Service commenced work with the family and undertook frequent visits, sometimes more often than once each week. The Family Support Worker found the home to be quite chaotic with little space and lots of clothing and toys around. It was also busy with several people seen visiting the home during some of the visits. The Family Support Worker remained involved throughout the period considered by this review.
Both parents were invited to attend the Solihull parenting course4. The mother did attend some sessions but was unable to complete the course due to the number she missed. These were undertaken at home with her. The father did not attend any sessions.

4 A 10 week parenting support designed to encourage parents/parents to be to think about the emotional development of their children, how to play together and to encourage positive parent/relationships.
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3.7 3.7.1

The mother was referred to Point 1 to attend a Circle of Security group5. She attended five of the eight sessions. This programme is not designed for couples to attend together and the father was not invited to attend.
Throughout the review period it was recognised that the parents were sometimes stressed and feeling low with some substance misuse. The significant overcrowding in the home was noted to be a particular source of tension. Initially the father was viewed as being supportive, although it was acknowledged that he himself found the home situation stressful. As time progressed and the mother’s mental health improved it was noted that the father engaged less with services and provided less support to the mother. The children were observed to have good interaction with the parents and it was considered that they were being kept safe, with no concern that they were at risk of significant harm.
Key Practice Issue 5 - Housing
In October 2015, the parents had applied for a housing transfer via the Home Options scheme due to overcrowding. Both parents had former tenancy debts to the Council and their application was prioritised in the bronze band as a result of these arrears. In March 2016, a housing support service started to work with the family to try to address their overcrowded housing situation. Also in March 2016, a welfare report was written by the parents’ housing provider due to the overcrowding. The health visitor, one of the schools and Children’s Social Care also provided information to support an increase in their priority banding for re-housing. These reports were reviewed by the Local District Council Housing Department but the banding remained unchanged due to the arrears. Effectively, this meant that they would not be re-housed whilst they had debts relating to their current or previous housing.
After it was known that the mother was pregnant, the housing situation became even more of a concern as there was going to be a seventh person living in the house. The housing support service helped the parents to establish a repayment plan for the arrears but it was going to take in excess of two years to clear the debt. In September 2016, around six weeks before AB1 was due to be born Children’s Social Care made a payment to clear the father’s arrears. The Children’s Social Care manager understood that there were no further debts and the family would be moved to gold banding and eligible to bid for appropriate properties.

5 An early intervention parenting model aimed at improving attachment and security between parents and young children.
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Subsequently, it became apparent that the mother still had debts that had to be cleared before the banding would be changed from bronze.
Key Practice Issue 6 - Mother’s Mental Health
The mother of AB1 was assessed by the Assessment and Focused Intervention Team of the Norfolk and Suffolk NHS Foundation Trust Mental Health Service in September 2015 and it was decided that she would be referred to the Community Mental Health Team. However, significant delays then followed before the mother was allocated to a member of the Community Mental Health Team. The initial delay arose because the referral to the Community Mental Health Team was not made until January 2016; four months after the assessment had been undertaken. A further three months later a duty worker from the Community Mental Health Team made a wellbeing call to the mother and two months later another such call was made. At this contact the duty worker ascertained that the mother was pregnant and requested that she be prioritised for service due to the pregnancy. A mental health practitioner from the team was allocated two weeks later and four weeks after allocation the Community Mental Health Team worker visited the mother for the first time. In total, 10 months passed between the assessment of AB1’s mother by Assessment and Focused Intervention in September 2015 and her starting to receive a service in July 2016. A second home visit by the Community Mental Health Team worker took place in September 2016 but no more visits took place prior to AB1’s death. The Community Mental Health Team worker did make two attempts to visit but the mother was out on the first occasion and in labour on the day the next visit was scheduled.
Key Practice Issue 7 - Services relating to the mother’s pregnancy and to AB1
The mother was late booking for her pregnancy but then engaged with maternity services. At the maternity booking appointment, in April 2016, she shared information with the midwife relating to her drug use and history and talked about the overcrowding situation at home. As a result of these concerns, the midwife completed a cause for concern form.
The mother engaged with antenatal services, attending clinic appointments as required. The father did not attend these appointments.
The health visitor, who already knew the family from providing support in respect of Sib4(1), undertook an antenatal appointment shortly after the pregnancy was confirmed. The health visitor and midwife undertook a

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