Lessons from Serious Case Reviews Dr Lizzie Aylett and Dr Jeremy Cox

What are they Statutory. Multiagency Frequent Stressful Labour intensive Sad

How many are there ? 2 in the last year! Average per year in Hertfordshire 2-4.

What do they tell us ? Many common themes Drugs Alcohol Domestic abuse Disability Repetition

CASE 3 Child A Findings Finding 1: A failure to use expertise within the professional network as to how children with different or complex communication needs express themselves, leads to the child’s voice not being heard. Finding 2: There is multi-agency confusion in Hertfordshire about the child in need processes for disabled children leaving them without effective outcome focussed plans and multiagency reviews. Finding 3: There is a Professional unwillingness to label the early signs of poor quality care provided to disabled children as Neglect leaving those children’s needs unaddressed.

CASE 3 Child A Findings Finding 4: A parent or carer not taking a child to health appointments, particularly where the child is additionally vulnerable, should be an indicator that the child may be at risk resulting in proactive follow up. Finding 5: There is a pattern of uncritical acceptance of parental self-report by professionals in all agencies which leaves children’s needs and circumstances unassessed. Finding 6: The meaning given by one agency to a phrase about a client does not necessarily have the same meaning for all agencies meaning that risk may be wrongly assessed by others. Finding 7: There is a pattern whereby non-resident Fathers are routinely excluded from assessments and decision making about their children.

What can we do ? Be aware Look for patterns Look for soft intelligence Consider referral Work with named professionals

Serious Case Review Baby Brad

Introduction Brad was 9 weeks old when he was admitted to Northampton General Hospital. The parents had taken him to the General Practice surgery that his right arm had been caught in his crib. An X-Ray confirmed that he had a spiral fracture to right humerus. Both parents were arrested that evening. Three days later Brad was discharged from hospital and was placed with foster carers. A serious case review was subsequently undertaken.

Antenatal care Brads Mum was 18 years old. His father was 21. Brad’s mother and father first attended the GP together on 11 th June 2012, records state that they were happy about the pregnancy. During her pregnancy, Brad’s mother attended for her antenatal appointments and both routine ultrasound scans; there was just one antenatal check that she did not attend on 24 th December GPs subsequently recalled that the couple attended all appointments together.

Learning points Both fairly young parents. No enquiry was made or recorded into their social welfare. There is increased risk of child abuse with younger parents. It might have been worth inquiring and noting down home circumstances. Mother subsequently alleged Domestic Abuse. As she was accompanied at all times by her partner, there had been no opportunity for the GPs to enquire about any problems in their relationship. Display contact information and try to create opportunities for women to disclose domestic abuse.

Baby Brad 3 weeks old At 3 weeks old Brad was taken to A&E with bleeding from the mouth, bruises on both cheeks and a broken clavicle. He was seen by the Paeds Reg but his injuries were wrongly attributed to over feeding and “poor parenting”. The broken clavicle was attributed to shoulder dystocia although there was no record of this in the labour notes. Section 47 enquiry was started by the hospital safeguarding nurse who subsequently reviewed the notes. Brad was discharged into care of the Maternal Grandmother The form was filled in promptly and comprehensively by the GP and scanned onto the notes. No alert put on the computer at that point

Learning Points Everyone makes mistakes! The reassurance from the hospital team was misleading. It was because of the safeguarding nurse that the child protection plan was put in place GP filled the form in correctly and scanned it onto the babys notes. It would have been a good idea to code “cause for concern” with an alert at this point. Make sure that any cause for concern is shared in-house

Baby Brad 5 weeks old At 8 weeks old the father rang the surgery on a Friday afternoon to report bleeding from the babies mouth. The GP was aware of the child protection concerns surrounding Baby Brad but only very vaguely. The GP spoke to the health visitor to ascertain if she had any child protection concerns. HV had visited the baby that day and did not think there was a risk to the baby. Parents presented very appropriately. The GP arranged for the baby to be seen on Monday morning

Learning Points Where there are child protection concerns, try to go the “extra mile” to ensure easy access and make sure the child is seen. Make sure that information is shared in-house. Read code when children are subject to a child protection investigation 3875 (case conference), 64c (child protection procedure) Teamwork is vital but don’t rely too heavily on other peoples opinions.

Next GP contact with Baby Brad Seen on Monday morning. No torn frenulum, baby was stripped down and examined Seen again later that week for the 6 week check and again was stripped down and examined. No Bruises were seen although the baby had already sustained several fractures by that time. Dad was accompanying Mum on all occasions. Seen again that week for his 6 week check, Stripped down and weighed. No bruises, no problems with handling.

Learning Points Bleeding from the mouth is a sign of child abuse The GP correctly stripped the baby right down to look for other bruises Bruises are not always apparent so also assess the childs behaviour and how they handle. Be alert for signs of Domestic Abuse and try to create opportunities to ask the Mother if thing are ok.

GP detected physical abuse At 10 weeks Baby Brad was brought by his parents with a limp arm. Parents claimed it had been caught in the bars of his crib The left arm was limp and pale with poor circulation GP correctly referred to local Paediatric team and also phone the social services safeguarding team Baby Brad had a broken arm as well as 9 other fractures including a fractured skull and ribs. Parents were arrested and Brad was placed in Foster care.

Learning Points There were similar lessons to be learnt in this case as in other SCRs Poor communication between agencies. The hospital letter outlining the presumed birth injury didn’t arrive at the practice until 17 weeks later! Opportunity to improve information sharing within the practice team. “Culture of optimism”. Everyone involved with the couple thought they were very nice people and good parents. Remember the voice of the child. Read Coding. The GP that took the phone call on Friday evening did not have a prompt to alert her to child protection concerns Domestic Abuse. No opportunity for GPs to ask the mother if things were alright at home.

What can we take back to our own Surgeries? Be alert for risk factors for child abuse, including young parents. Ensure regular safeguarding training. Read code if there is an ongoing Section 47 enquiry Have regular meetings with GPs and Health visitors to discuss child protection concerns and ensure information is circulated to all clinicians who miss the meeting. Encourage all team members, including Reception, to allow easy access to care for families at risk. Maintain a degree of scepticism about what parents are telling you in order to keep the childs best interests at the heart of the matter. Try to create opportunities to speak to mothers alone if possible.