1. Presentation to Swindon Safeguarding Children Board Conference 12 October 2016 Helen Davies

2. 2 Serious Case Reviews Child D aged 2 weeks March 2013 – March 2015
Child S aged 8 weeks April – October 2015
Focus on learning for organisations – systems
Not yet published

3. Common themes Co sleeping on sofa
Well known to agencies – child protection plans/interim supervision order
Neglect
Maternal ill health
Mothers’ traumatic childhoods/older children in care

4. Positives Prompt visits to mothers and babies after hospital discharge
Safe sleeping addressed
In 2015:
Multi agency working
Strong commitment
Focus on children/ siblings – advocates
Identification of neglect
Effective safeguarding procedures – core groups
Care proceedings

5. Learning Gaps in communication GPs and social workers
Between hospitals
Between hospital and health visitor/midwife
Between hospital and social worker
Hospital checks re CP plan
Hospital not thinking child
Failure to convene discharge planning meetings

6. Learning Gaps in assessment Lack of chronology on social work file
Mother’s mental health diagnosis
Mother’s alcohol and drug use
Nature of mother’s seizures
Identity of male partners and their parenting capacity
Father’s role in family
Viability of grandmother
Measuring change and outcomes (health visiting)
All relevant information in hospital records not known to midwives

7. Identification of capacity to change
Learning (cont)
Identification of capacity to change
Impact of mother’s childhood on parenting
Impact of her lifestyle
Apparent changes taken at face value
False optimism

8. Mothers/impact on staff
Learning (cont)
Mothers/impact on staff
Needy care leaver
Distracted by her own needs
Disguised compliance
Impact of traumatic pregnancy and major surgery/effects of strong painkillers
Impact of period in ICU on health and functioning

9. Learning (cont) CP Processes Few core group meetings
Implementation of CP plan not addressed at reviews
Paediatrician not at strategy meeting
No pre birth conference

10. Learning (cont) Escalation No escalation by Conference chairs
Health visitor
Community midwife

11. Learning (cont) Legal processes Ample evidence to use it (D)
Delays in convening meeting before action (7 months)
Delays in completing required assessments
Removal in context of neglect

12. Organisational issues
Learning (cont)
Organisational issues
Changes of social workers and managers
Health visitor workload/supervision
Workload of safeguarding midwife
Delay in community paediatric assessment
Cover for vulnerable baby when health visitor not available
Hospital IT systems

13. Questions What changes are necessary in light of these findings?
What recommendations would you make to the Safeguarding Children Board?
What might be the barriers to making the changes?