norfolk safeguarding children board serious case review ...€¦ · of ab1 and the father of ab2...

Norfolk Safeguarding Children Board

Serious Case Review

concerning AB1 & AB2

Overview Report

Lead Reviewer: Peter Ward Published: June 2019

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Table of Contents Page 1. Introduction

3

2. The Review Process

3

3. AB1 – Family Circumstances and Key Practice Issues

5


11

5. Consideration of Key Research Questions

15

6. Learning from the Review

39

7. Recommendations

42

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1. Introduction

1.1 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.

2. The Review Process

2.1 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

findings.

2.2 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.

2.3 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

Association

2.4 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.

2.5 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

2.6 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.

2.7 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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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.

2.8 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.

3. AB1 – Family Circumstances and Key Practice

Issues

3.1 Introduction

3.1.1 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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3.2 AB1

3.2.1 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.

3.2.2 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.

3.3 Key Practice Issue 1 - Referral to Children’s Social Care and

subsequent Child In Need Plan

3.3.1 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.

3.3.2 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.

3.3.3 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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➢ The need for the father to be involved in caring for the children

whilst the mother was recovering from her psychosis and regaining

confidence.

3.3.4 As time moved on and the mother became pregnant additional action

points were added to the plan relating to the needs of the baby.

3.3.5 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.

3.4 Key Practice Issue 2 - Mother’s substance misuse

3.4.1 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.

3.4.2 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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her from the service after the mother had cancelled two appointments in

the first three weeks after AB1 was born.

3.5 Key Practice Issue 3 - Father’s substance misuse

3.5.1 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.

3.5.2 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.

3.5.3 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.

3.6 Key Practice Issue 4 - Support with child care issues

3.6.1 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.

3.6.2 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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3.6.3 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.

3.6.4 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.

3.7 Key Practice Issue 5 - Housing

3.7.1 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.

3.7.2 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.

3.8 Key Practice Issue 6 - Mother’s Mental Health

3.8.1 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.

3.9 Key Practice Issue 7 - Services relating to the mother’s pregnancy

and to AB1

3.9.1 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.

3.9.2 The mother engaged with antenatal services, attending clinic

appointments as required. The father did not attend these appointments.

3.9.3 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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home joint visit at approximately 25 weeks gestation; both parents were at

home but the father did not join in the visit.

3.9.4 Six weeks before AB1 was due to be born, Children’s Social Care

commenced a pre-birth assessment. This was completed three days after

AB1 was born with a recommendation to continue with the Child in Need

plan with a view to stepping down to Early Help once housing issues were

resolved. Prior to completing the assessment, the social worker visited

the mother and AB1 in hospital where the mother said that the father was

being very supportive.

3.9.5 AB1 and his mother were discharged from hospital the day after AB1 was

born. Community midwives undertook home visits on the second, third

and fifth days of his life. Subsequently, three midwifery appointments

were offered at the community hospital but AB1 was not brought to any of

these. The community midwife was notified of this non-attendance and

intended to offer another home visit. However, AB1 died before she was

able to do so.

3.9.6 The health visitor undertook a new birth visit when AB1 was 13 days old

which did not indicate any concerns. The health visitor undertook another

home visit one week later and again there were no concerns with AB1 or

Sib4(1) who was also seen. The mother stated that the father was

supportive. The social worker and family support worker undertook a joint

home visit when AB1was 15 days old and saw both parents.

3.9.7 When AB1 was four weeks old, the family support worker accompanied

the mother and AB1 to a postnatal group. The mother expressed a

willingness to attend the next meeting but wanted the family support

worker to accompany her again for support.


4.1 Introduction

4.1.1 This section of the report provides brief information about the

circumstances of AB2’s birth and death, his family circumstances and a

factual summary of key areas of agency involvement with the family. As

with Section 3, 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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4.2 AB2

4.2.1 AB2 was born unexpectedly at home, in December 2016, with paramedics

present; the pregnancy was full term. He was subsequently admitted to

Neonatal Intensive Care Unit due to suspected sepsis and started on a

five day course of antibiotics. On day five AB2 and his mother were

discharged to the family home which was also occupied by AB2’s father,

maternal half-sister aged 10 years (Sib2(2)) and a sister aged 25 months

(Sib3(2)). The house was a two bedroom house rented from a housing

association. During most of the period considered by this review the

father’s teenage son (Sib1(2)) had also lived in the family home. He

returned to live with his mother in another part of England prior to the birth

of AB2.

4.2.2 Approximately six weeks after AB2’s birth, his father found him

unresponsive under the covers of the parental bed. AB2 had apparently

suffocated and tragically died whilst his parents slept in the bed. Both

parents had been drinking alcohol the previous evening. Toxicology tests

undertaken on the day AB2 died, found cocaine in the blood stream of

both parents, which indicated use within the previous 24 hours. Both

parents admitted charges of child neglect.

4.3 Key Practice Episode 1 - Domestic abuse & alcohol misuse

4.3.1 Prior to the period covered by this review, Police were called to eight

domestic incidents between mother and father of AB2 between May 2014

and 17 September 2015. Five of these were during a period of less than

four months between November 2014 and February 2015. These

incidents were mainly verbal arguments, although one included

allegations of physical violence. Seven of the reports include reference to

the father being under the influence of alcohol and on occasion it was also

noted that the mother had been drinking.

4.3.2 Four of the incidents resulted in notifications to Children’s Social Care. In

February 2015, following the incident which included allegations of

physical violence, Children’s Social Care carried out an initial assessment.

The incident was described as a one off and it was concluded that the

parents had shown understanding and insight into the impact of the

incident on Sib2(2). Children’s Social Care took no action in respect of a

verbal argument that took place less than two months later. Another

incident five weeks after this resulted in a recommendation from

Children’s Social Care that the mother seek support in the form of a

Family Support Process and a request for the health visitor to visit.

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4.3.3 Within the 12 month period covered by this review, the Police attended

one domestic incident between the parents. This was in early February

2016 and occurred when the father came back from shop with a bottle of

vodka and mother poured it away. Although the mother called the Police

she initially refused to provide a statement and subsequently retracted the

allegation. The father was charged with assault and bailed to stay away

from the family home but was not prosecuted and returned to the family

home. No domestic incidents were reported after this date

4.3.4 In September 2016, when AB2’s mother was 28 weeks pregnant, the

health visitor and midwife carried out a joint home visit to the mother in

connection with her pregnancy with AB2 they discussed concerns around

previous domestic abuse. The mother told them that things had been

much calmer with no further incidents of domestic abuse and the father

taking his parental responsibilities seriously. She added that he no longer

drank to excess. Three weeks later the health visitor undertook an

antenatal visit during which the mother reiterated that there had been no

more incidents of domestic abuse and said that the father had stopped

drinking. A further three weeks later, the social worker saw both parents

during a home visit and the father implied, via a scaling question, that the

overcrowded home was affecting his mood and leading to him drinking.

This was not explored further.

4.4 Key Practice Issue 2 - Social work assessments

4.4.1 Two social work assessments were undertaken during the period covered

by this review. The first assessment was undertaken as a result of the

domestic incident that took place in early February 2016. On 12 June

2016 the assessment was completed with a recorded outcome that there

would be no further action from Children’s Social Care as the parents did

not want Child In Need support or Family Support Process.

4.4.2 The second social work assessment was undertaken in October and

November 2016 following a referral from Sib1(2)’s school. Prior to the

conclusion of the assessment Sib1(2) returned to his mother’s care, the

assessment was discontinued and Children’s Social Care ceased their

involvement with the family.

4.5 Key Practice Issue 3 – Housing

4.5.1 The family lived in a two bedroom, rented property. When Sib1(2) joined

the household, both parents lived in the house along with two girls and a

boy. It was noted in the first assessment undertaken by Children’s Social

Care that the house was overcrowded and that Sib1(2) was sleeping in

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the only reception room. It was also noted that the mother said she was

actively looking for house exchanges.

4.5.2 The mother had lived in the house for several years and had ongoing rent

arrears. She enquired to the housing provider about applying for a mutual

exchange with another social housing tenant but there is no indication that

the application was ever received or that she ever disclosed or

complained that the property was overcrowded.

4.5.3 During the visit that the health visitor and midwife made to the mother at

28 weeks gestation, the mother said that the family been accepted for a

housing exchange to a much bigger property and this would provide much

needed additional space. This visit was about a month after the mother

had enquired about applying for a mutual exchange.

4.5.4 Housing was discussed when the social worker visited three weeks later

although there is no record of whether a possible move was discussed.

The following week the health visitor was told by the mother that the

planned housing exchange had fallen through and the lack of space was

proving stressful for everyone. It was agreed that the health visitor would

write a letter of support to the housing department. This was done five

weeks later.

4.5.5 Once the paternal half-brother had returned to his mother’s care the

immediate issue of overcrowding was of less concern as there was one

bedroom available for the parents and a second for Sibs 2(2) and 3(2).

This was six weeks or so before the expected date of delivery for AB2.

4.6 Key Practice Issue 4 - Services relating to the mother’s pregnancy

and to AB2

4.6.1 The mother presented in a timely fashion for her pregnancy and engaged

with antenatal services throughout the pregnancy. There is no indication

that the father attended antenatal appointments with her.

4.6.2 Following confirmation of the mother’s pregnancy with AB2, the midwife

submitted a cause for concern notification because the mother had stated

that the family had had previous social work involvement. The notification

highlighted a history of domestic abuse from the father and noted that

Sib1(2) was living with the family. The following week the midwife liaised

with the health visitor and made the health visitor aware of the cause for

concern notification.

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4.6.3 At 28 weeks gestation, the health visitor and midwife carried out a joint

visit to the mother. They discussed behaviour issues relating to Sib1(2)

and the mother said that he had settled down and his behaviour had

improved. 2½ weeks after this visit, the midwife completed a pre-birth risk

assessment highlighting the issues that had been discussed and noting

that the mother was adamant that the father’s abusive behaviour was no

longer an issue. Further antenatal visits were undertaken at 31 and 35

weeks gestation

4.6.4 Following AB2’s discharge from Neonatal Intensive Care Unit, midwives

visited three times over the next 10 days before discharging the mother to

health visiting services. No concerns were raised over this time. On the

day of discharge from midwifery care, a new birth visit was undertaken by

a different health visitor to the one who had seen the family previously.

The whole family was seen during this visit.

4.6.5 The following month, AB2 was seen by GP1 for his six - eight week

developmental assessment. No concerns were noted although AB2

presented as unsettled with a suggestion that this was due to infantile

colic.

5. Consideration of Key Research Questions

5.1 Key Research Question 1

To what extent did agencies consider and engage with the whole

family, including both parents, all children and unborn children and any

other significant care providers? Was there sufficient involvement with

the fathers and a consistent approach with the mothers and fathers?

AB1

5.1.1 In the case of AB1, the initial social work assessment, considered the

whole family. The subsequent action plan contained actions relating to

both parents but only one action specifically relating to any of the children.

Subsequently, the monthly Child in Need meeting was the main forum for

agencies to work with the parents and with one another to co-ordinate

services and review progress. The content of the minutes suggest that

both parents attended the majority of the meetings and that there was

engagement with them both at these meetings. It is also clear from the

content of the minutes that both parents were considered at the meetings.

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5.1.2 Over the course of the Child In Need plan the mother’s mental health

improved and there was improved engagement with the Child in Need

process. Paragraphs 3.4.1 and 3.4.2 of this report show that her

engagement with Norfolk Recovery Partnership services was mixed with

better engagement when practitioners visited her in her own home rather

than expecting her to travel. She attended some sessions of the Solihull

parenting course and the Circle of Security group but did not consistently

do so. The mother’s pregnancy appears to have been a motivating factor

that resulted in better engagement with services and in particular provided

her with motivation to abstain from alcohol and drugs. The drug workers

and family support workers showed good commitment to the mother and

supported her in engaging with other services. Once the mother was

pregnant, the midwifery service was able to engage with her for antenatal

care and the health visitor was appropriately involved.

5.1.3 At the start of the Child in Need process, the mother’s mental health was

poor and the father was identified as the person who needed to ensure

that the children were cared for and kept safe. This suggests that there

was engagement with the father although it is unclear to what extent

practitioners such as the family support worker and social worker engaged

directly with him during visits and to what extent they relied on the mother

to tell them the level of support she was receiving. The mother now

considers that she overstated the level of support the father provided

because she was worried that the children would be removed from her

care. She feels that there was much more expectation on her to abstain

from alcohol and drugs than there was on the father.

5.1.4 The father was sometimes present in the house when professionals

visited but their engagement with him during these visits varied. He has

been described as ‘difficult to engage’ and it has been said that he would

often stand back or be in a different room although he sometimes

contributed to discussions. Overall it appears that professionals allowed

the father to determine whether or not he engaged with the visits; there

was no expectation that he would do so and appointments were not

specifically made with him.

5.1.5 As time passed and the mother’s mental health improved there was

increasing concern that the father was drinking more and was not

engaging with services or supporting the mother to the extent that he had

previously done. These concerns were identified and there appears to

have been some challenge of the father. However, agencies were too

ready to believe his assurances that things would improve and allowed

the situation to drift when improvements were not forthcoming.

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5.1.6 For example, at Child in Need meetings in May and June 2016 it was

recorded that the plan was heading in the right direction but there were a

few concerns around father who was happy to be supported to address

them. He did not attend the next Child in Need meeting and when he

attended one after that, in September 2016 concerns were again raised

about his cooperation. At this meeting it was noted that he had admitted

drinking occasionally and that he was becoming more frustrated, less

motivated and secretive about his whereabouts. It was also noted that he

acknowledged his recent lack of engagement and reported that he would

change his attitude.

5.1.7 However, he failed to attend the following Child in Need meeting, shortly

after AB1 was born and it was reported that he had totally disengaged

from Norfolk Recovery Partnership. The evaluation in the minutes of that

meeting, states:

“The plan is progressing well. The mother's mental health is stable.

She is now more confident and able to make wise decisions for her

family. She has given birth to a new baby and her family have been

supportive. The only problem is that the father has started to withdraw

from the plan. This can make things complicated however with the

motivation that the mother has at the moment, she will be better

equipped to care for her children.”

Whilst this statement recognises that the father had withdrawn from the

plan it minimises the importance of this. There is no acknowledgement of

the additional stresses and strains that the mother will face if the father is

unsupportive, absent from the home or misusing substances.

5.1.8 When the father referred himself to Norfolk Recovery Partnership in July

2016 (see paragraph 3.5.2) this was with encouragement and assistance

from the drug worker who was working with the mother. Subsequently, he

was expected to attend visits at a clinic and did not attend. Better

progress might have been made if the drug worker had undertaken home

visits in the way that the mother’s drug worker did.

5.1.9 Considerable engagement took place with Sib4(1) who was below school

age and with her mother during most of the contacts that occurred.

Monthly wishes and feelings work was undertaken by school with two of

the siblings and this information was fed into the Child in Need meetings.

The school that the other sibling attended was present for the Child in

Need meetings up until March 2016 but absent for subsequent meetings.

There is no evidence that this child’s wishes and feelings were

ascertained and fed into the Child in Need process when the school did

not attend. One of the action points on the child in need plan specifically

concerned the wellbeing of this child but the child was not being taken to

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appointments. Neither the school nor the service that was offering the

appointments were present at Child in Need meetings. Therefore

opportunities were missed to address the missed appointments and to

elicit help ensuring that the child attended. Additionally, it would have

been appropriate to consider whether this child should be invited to attend

for at least part of the Child in Need meeting to contribute their wishes and

feelings.

5.1.10 The Lead Reviewer has not seen any information to suggest that

agencies engaged with the wider family network, including the

grandparents and the other parents of Sibs1(1), 2(1) and 3(1). Given that

the social work assessment had identified strong networks of support (see

paragraph 3.3.2) it would be expected that services would have engaged

with them during the period of the Child in Need plan.

5.1.11 It is recorded in the pre-birth social work assessment that the social

worker spoke to the mother three times as part of the assessment.

However, no reference is made to the social worker speaking to the

father, any of the children or any of the extended family. As the family

were already subject to a Child In Need plan the social worker was

already familiar with the family members. Nevertheless, they should have

been involved in the assessment.

5.1.12 Following the birth of AB1, appropriate and timely visits were carried out

by the midwife, health visitor and social worker. The mother was asked to

attend postnatal midwifery appointments at a community hospital but did

not do so. To attend these appointments the mother would have been

required to undertake a journey involving two buses each way with her

new born baby and Sib4(1). The review panel consider that it was

unrealistic to expect the mother to attend at the community hospital and it

would have been more appropriate to have offered all postnatal follow up

at home. After the mother missed these appointments a midwife tried to

contact her to arrange a home visit. Unfortunately, as explained in

paragraph 3.9.5, AB1 died before this contact was made.

5.1.13 The mother cancelled two appointments with the drug worker and neither

parent attended a Child in Need meeting held nine days after AB1 was

born. The Lead Reviewer has concerns about the decision of Norfolk

Recovery Partnership to cease involvement with the mother when AB1

was just three weeks old and does not know what evidence there was for

the view that there was little risk of relapse (see paragraph 3.4.2). The

issues within the household that had been identified at the start of the

Child in Need plan had not significantly changed. The addition of a new

born baby to an already overcrowded house was likely to create additional

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stress, the father was known to be drinking and the mother no longer had

the risk of damage to an unborn child as an incentive to abstain. These

factors together could be viewed as risk factors for a relapse.

Furthermore, the Lead Reviewer considers that the decision to discharge

the mother over the phone was inappropriate.

5.1.14 The Lead Reviewer also has some concern about Children’s Social

Care’s decision to consider disengaging after the next Child in Need

meeting. AB1 would have been around six weeks old at the time of that

meeting and therefore he would still be a very recent addition to the

family. It is likely that the risk factors identified in the previous paragraph

would have still been in place and the mother would not be receiving

support from Norfolk Recovery Partnership. In view of these factors the

Lead Reviewer questions whether it would have been prudent for

Children’s Social Care to maintain involvement for at least another month

to monitor progress. The Lead Reviewer does, nonetheless,

acknowledge that no definite decision had been taken to end the Child in

Need plan.

AB2

5.1.15 At no time within the period under consideration was the family of AB2

subject to any ongoing child care process such as child in need or family

support and therefore there was never a multi-agency plan. Similarly,

neither parent was referred to any support services. Consequently

engagement with the family tended to be on an individual agency basis

regarding specific issues.

5.1.16 During the first assessment undertaken by Children’s Social Care each

member of the nuclear family was spoken to/seen at least twice during the

assessment and there was also consultation with the other parents of the

older siblings. Wider family networks, such as grandparents were not

explored although historical Police notifications show that the mother’s

sister had been a supportive person during previous domestic incidents.

The second assessment focussed on Sib1(2) rather than the family as a

whole. The mother and father and Sib1(2)’s birth mother all contributed

as did Sib1(2). However, there are concerns with the thoroughness of

both assessments and these are considered in Section 5.3 below.

5.1.17 There is no evidence of any wishes and feelings work being undertaken

with Sib2(2) by the school and concerns regarding her presentation were

not suitably addressed by agencies. The health visitor referred Sib2(2) for

appropriate support when the mother raised concerns during a home visit.

It was good practice on the part of the health visitor to respond to the

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mother’s concerns but the health visitor did not communicate this action

with the child’s school and therefore missed an opportunity to elicit

support in addressing the concerns.

5.1.18 There are no records of the midwifery service engaging with the father

although he was considered by the midwife when a pre-birth risk

assessment was completed. This risk assessment identified historical

issues of domestic incidents and alcohol misuse by the father and an

overcrowded house. Similarly, the health visitor did not engage with the

father but considered him in discussions with the mother. In both cases

the mother was adamant that there was no longer an issue with the father

misusing alcohol or becoming argumentative.

5.1.19 Staff from the housing provider tried to engage with the parents to help

them to maximise their income and address their rent arrears. The

mother was the tenant and the father was known to live there

intermittently. This created some difficulties because the father was in

employment which had an impact on the mother’s benefit entitlement

when he was living there. The housing provider’s view was that the house

was well kept with evidence of lots of toys for the children. Housing staff

were not aware of the mother’s pregnancy with AB2 but never had

concerns about the welfare of the children.

Both cases

5.1.20 Historically and traditionally mothers have provided the majority of child

care within families and still do so. Furthermore, the majority of

practitioners working within childcare services are women. It is perhaps

no surprise that practitioners primarily engage with mothers and indeed, in

many cases, this is appropriate. Nevertheless, numerous serious case

reviews have identified the importance of engaging with significant males.

This is important in order to identify and address potential risks they might

pose, to impart information to them that will help them to care for their

children appropriately and to gain a more holistic assessment.

5.1.21 Brandon et al’s biennial analysis of serious case reviews published in 2009

identified the following:

‘The failure to know about or take account of men in the household was

also a theme in a number of serious case reviews. Assessments and

support plans tended to focus on the mother’s problems in caring for her

children and paid little attention to the men in the household and the risks

of harm they might pose to the children given histories of domestic

violence or allegations of or convictions for sexual abuse. The failure to

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take account of men in assessments occurred sometimes even when

good information was available.’ (p52)6

5.1.22 More recently, the Lead Reviewer has been involved in several serious

case reviews where babies have died and there has been a lack of

engagement with fathers. This has included straight forward measures

such as not asking for or recording the names of people accompanying

mothers to appointments. It has also included professionals not including

carers other than mothers in assessments and not providing them with

information to help them to keep a baby safe.

5.1.23 Within Norfolk itself, a serious case review concerning Family L, which

was commissioned in 2014, found that professionals involved in the CAF

process were not commonly seeking the active participation of the less

visible parent (usually the father). This made them less visible to the

professional process and risked the loss of valuable information about

parenting and children. The review posed seven questions for Norfolk

Safeguarding Children Board and partner agencies to consider in order to

address this finding.

5.1.24 Involving fathers in maternity care is additionally complicated because the

mother to be, rather than the unborn baby is the service user and the

focus of interventions. Furthermore, it is desirable for midwives and

health visitors to have some contact with the mother without her partner

present in order to ask questions about possible domestic abuse within

the relationship. Nevertheless, it should be expected that fathers will

engage in some parts of the antenatal and postnatal processes. Pro-

active steps should be taken by relevant services to encourage them to do

so and to challenge them over non-engagement. It was stated at a

Learning Event that fathers are often at work when visits take place. This

was the case with the father of AB2 but not with the father of AB1.

5.1.25 Signs of Safety has been adopted as the basis of work with children

across partner agencies engaged in providing services for Children in

Norfolk. Family Networking is an integral component of the Signs of

Safety approach. It assists young people and their families to build

support and resilience within their own network and empower those

networks to share responsibility for a child and young person’s safety,

wellbeing and permanence. Norfolk Children’s Services run a programme

of two days training which follows on from the Signs of Safety Foundation

training to support practitioners and managers in undertaking Family

6 Brandon, M., Bailey, S., Beldersone, P., 2009, Gardner, R., Sidebotham, P., Dodsworth, J. Warren, C. and Black, J. Understanding serious case reviews and their impact: a biennial analysis of serious case reviews 2005–2007, DCSF, 2009

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Network Meetings at all stages of involvement with Children, Families and

Carers. In addition, three hour briefings are available for staff who need

to understand the rationale and process for Family Networking but do not

provide services directly to children and families/carers.


What information was given to the parents regarding safe sleeping and

the dangers associated with co-sleeping? How was the information

given and who was it given to? What was done to check both parents’

understanding of safe sleeping and to ensure that they were following

the advice given? Was information about safe sleeping appropriately

reinforced by all agencies?

5.2.1 In both cases it is documented that routine antenatal advice, including

safer sleeping advice, was given to the mothers by the health visitor

during an antenatal visit. In the case of AB1 it is documented that this

advice was reiterated by a different health visitor during the new birth visit

when AB1 was 13 days old.

5.2.2 It seems unlikely that safer sleeping advice was given directly to either

father or to other family members. In the case of AB1 it is reported that

the father was in the house when the joint antenatal visit took place but

remained in the kitchen and did not engage with the visit. The health

visitor said that she may have raised her voice to try to make him hear

what was being discussed but there is no indication that she pro-actively

tried to ensure that he was given and understood the advice. It is

recorded that during the new birth visit, the mother reported being aware

of safer sleeping advice and had been putting AB1 in a bassinet. It is also

recorded that the father prepared the feed and was in the background

caring for an older child. In the case of AB2, the health visitor has said

that, during the antenatal visit, she went through the relevant booklet and

left this for the mother to share with the father. The father was seen

briefly during the birth visit but safer sleeping was not discussed.

5.2.3 It is standard practice for safer sleeping advice to also be given by

maternity staff on discharge from the maternity ward and during postnatal

midwifery visits. There is no documented evidence of this being done in

either of these cases and it has not been possible to clarify what

information was given and who it was given to. The Midwifery Service is

now using an electronic record which requires midwives to record whether

safer sleeping advice has been given. This does not specifically state to

whom the advice has been given.

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5.2.4 Notwithstanding the limited occasions when midwives and health visitors

had documented giving safer sleeping advice to parents, it was the belief

of professionals attending the Learning Events that it is established

practice for them to provide such advice to mothers. There was less

confidence that this advice is directly provided to fathers and others who

may provide significant care to the baby. Section 5.1 of this report

identifies that maternity and health visiting staff primarily work with

mothers. This is understandable, and in respect of some issues such as

asking about domestic abuse, desirable. Nevertheless, it is important that

midwifery and health visiting staff do engage with fathers and other

primary carers when imparting information connected to the safe care of

babies. Safer sleeping advice certainly fits within this category.

5.2.5 Health visitors give parents a booklet entitled ‘Safer Sleep for Babies – a

guide for parents’. This is produced by the Lullaby Trust, an organisation

which “raises awareness of sudden infant death syndrome (SIDS),

provides expert advice on safer sleep for babies and offers emotional

support for bereaved families”7. This booklet specifically and solely

addresses safer sleeping for babies and reducing the risk of Sudden

Infant Death Syndrome. It includes a number of key do’s and don’ts in

clear language and large font.

5.2.6 The mother of AB1 confirmed to the Lead Reviewer that she had been

given safer sleeping advice, including a copy of the aforementioned

booklet. However, she believes that the message needs to be stronger;

especially around not drinking when you are caring for a baby. She cited

other mothers in her postnatal class saying that they were co-sleeping

and the mother considers that this was not challenged strongly enough by

the facilitator. Her view is that there needs to be a shocking message that

will scare people. The father of AB2 confirmed to the Lead Reviewer that

he and his partner were aware of safer sleeping advice and had been

given the Lullaby Trust booklet. However, AB2 would not settle in his

bassinet and, like his older siblings before him, regularly slept with his

parents in their bed. AB2’s father thinks that the health visitor had been

aware of this and had advised against it but said that he and his partner

ignored the advice because they did not believe it would happen to them.

5.2.7 During the learning event, agencies accepted that when they are working

with men and women who have, or will soon have a baby to care for, they

have a responsibility to reinforce the safer sleeping message. However,

there is no evidence that anyone other than the health visitors and

7 https://www.lullabytrust.org.uk/ retrieved 17 October 2018

https://www.lullabytrust.org.uk/

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midwives did so. The Lead Reviewer does not know why this did not

happen or whether this is an ongoing issue.

5.2.8 The Rapid Response visit carried out on the day of AB1’s death found a

bassinet in the lounge which was positioned alongside the sofa and was

fit for purpose with a sheet on the mattress. This lends some support to

the mother’s statement that she intended for AB1 to sleep in the bassinet

that night rather than a co-sleeping arrangement.

5.2.9 Babies are at increased risk if they co-sleep with a parent who smokes or

has taken drugs or an alcoholic drink. It was known by agencies that

there was alcohol and substance misuse within the family of AB1 and

alcohol misuse within the family of AB2. Therefore it should have been

recognised that the babies would be at increased risk if co-sleeping took

place. Consequently, these were families where it was particularly

important to ensure that the safer sleeping message was strongly

delivered to both parents. There is no indication that either family was

identified as high risk in relation to co-sleeping. The Lead Reviewer does

not know why this was the case.

5.2.10 It was also recognised that both families were living in overcrowded home

conditions. The Lead Reviewer considers that where overcrowding is an

issue it is particularly important that professionals emphasise the risks of

co-sleeping and check that the baby has a safe space in which to sleep.

In the case of AB1, the mother has said that it was because of the

overcrowding that she was sleeping on the sofa, which in itself increases

the risk to a baby if they co-sleep.

5.2.11 The Norfolk Safeguarding Children Board website includes a document

‘Safer Sleeping guidelines for Professionals’ dated September 20148.

These guidelines include the following key messages that may have not

been consistently followed with the families of AB1 and AB2:

“The message has to be delivered on a number of occasions and be

consistent. Parents soon pick up on inconsistent advice; this may lead

them to disregard it completely. It is essential that every opportunity is

taken to promote the safer sleeping message using the resources

available by all of workers delivering services to a family.” (page 5)

“This is not solely a health responsibility; this is a responsibility for all

agencies in contact with parents of young babies.” (page 5)

8 https://www.norfolklscb.org/wp-content/uploads/2015/04/Safer-Sleeping-Guidelines-2014.pdf. Retrieved 23 October 2018

https://www.norfolklscb.org/wp-content/uploads/2015/04/Safer-Sleeping-Guidelines-2014.pdf

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“Take opportunities on every home visit, before and after birth, to see

where the infant sleeps - parents are often keen to show what

arrangements they have made.” (pages 5 & 6)

“Make sure you include both mother and father in your discussions

and, where possible, any other carers, particularly grandparents. It is

likely that new parents will seek advice from their wider family and it is

important that these key figures are aware of the safer sleeping

message.” (page 6)

“Check and re-check how parents have understood the message.”

(page 6)

“On every occasion where safer sleeping advice is given or the infant’s

sleeping arrangements are assessed a written record should be made.”

(page 6)

5.2.12 The guidelines also include specific guidance for individual organisations

which work with families.

5.2.13 Quality Statement 4 within the NICE guidance regarding postnatal care is

that “Women, their partner or the main carer are given information on the

association between co-sleeping and sudden infant death syndrome

(SIDS) at each postnatal contact.”9

5.2.14 In both these cases the safer sleeping message was at the very least

given to the mothers and in the case of AB1 it is known that the mother

understood the advice. It is also clear that both babies had a suitable

place to sleep. The fact that, despite this, both died whilst co-sleeping

reinforces the need to deliver this message several times and to deliver it

in a strong way.

5.2.15 In July 2018, a review undertaken by Garstang J and Sidebotham P from

University of Warwick was published in the Archives of Disease in

Childhood journal. This review examined 27 serious case reviews where

sudden unexpected infant death had occurred between 2011 and 2014.

The reviews found the following:

➢ In 19 of the 27 cases, parental drug or alcohol use was directly

involved in the lead up to the infant's death;

➢ 16 cases involved co-sleeping and substance use was a factor in 12 of

these;

9 https://www.nice.org.uk/guidance/qs37/chapter/Quality-statement-4-Infant-health-safer-infant-sleeping. Retrieved 23 October 2018

https://www.nice.org.uk/guidance/qs37/chapter/Quality-statement-4-Infant-health-safer-infant-sleeping

https://www.nice.org.uk/guidance/qs37/chapter/Quality-statement-4-Infant-health-safer-infant-sleeping

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➢ In 13 cases parents had been given safe sleep advice prior to the

death of their babies;

➢ 18 cases identified parents' unwillingness to engage with services.10

5.2.16 The researchers recommended that children's professionals help parents

who use drugs and alcohol to develop safe sleep practices and that

additional research into how best to deliver safe sleep messages to high-

risk families is needed.11

5.2.17 A search of the NSPCC repository of Serious Case Reviews shows that

since 2016, eight SCRs have been published following the death of an

infant where co-sleeping was believed to be a factor. In seven of these

alcohol and/or substance misuse was also a factor.12

Changes regarding safer sleeping advice since the deaths of AB1

and AB2.

5.2.18 Norfolk Children and Young People’s Health Services have developed a

Norfolk focused website ‘Just One Norfolk’ (justonenorfolk.nhs.uk). This is

an innovative resource which is aimed at promoting and supporting self-

care and behaviour change. It does this by providing parents, carers and

young people with the knowledge, skills and confidence to take care of

their own and their family’s health and wellbeing, with facility to easily

seek more support when needed. The site has been co-produced with

parents and is designed to be accessible, understandable, interactive and

informative. It includes information in various formats in relation to

promoting safer sleeping.

5.2.19 During 2018 a Safer Sleeping Campaign has been designed in Norfolk

with the following objectives:

➢ “To reduce child deaths due to Sudden Infant Death Syndrome (SIDS)

➢ To change behaviour and action sleep safe messages

➢ Raise awareness of sleep safe messages with the target audience”13

5.2.20 The target audience is:

➢ “Parents and carers of young babies

10 https://www.cypnow.co.uk/cyp/news/2005572/health-visitors-must-ask-parents-about-alcohol-to-combat-sudden-infant-deaths. retrieved 26 October 2018 11 Ibid 12 https://learning.nspcc.org.uk/case-reviews/national-case-review-repository/?_t_id=1B2M2Y8AsgTpgAmY7PhCfg%3d%3d&_t_q=serious+case+reviews&_t_hit.id=Nspcc_Web_Models_Pages_TopicPage/_a56d40c5-2707-46ca-a41e-0d5a1a5d9463_en-GB&_t_hit.pos=8 Retrieved 23 October 2018 13 Safer sleeping campaign summary (April 2018)

https://www.cypnow.co.uk/cyp/news/2005572/health-visitors-must-ask-parents-about-alcohol-to-combat-sudden-infant-deaths

https://www.cypnow.co.uk/cyp/news/2005572/health-visitors-must-ask-parents-about-alcohol-to-combat-sudden-infant-deaths

https://learning.nspcc.org.uk/case-reviews/national-case-review-repository/?_t_id=1B2M2Y8AsgTpgAmY7PhCfg%3d%3d&_t_q=serious+case+reviews&_t_hit.id=Nspcc_Web_Models_Pages_TopicPage/_a56d40c5-2707-46ca-a41e-0d5a1a5d9463_en-GB&_t_hit.pos=8




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➢ Pregnant mums

➢ Health care professionals

➢ All professional agencies that might come into contact with new

parents

➢ Holiday and tourism industry”14

5.2.21 A key aspect of the campaign was “To produce a film to promote a

scenario which depicts a family losing a baby to SIDS”15 along with

“supporting resources and advice information sheets.”16 This has been

funded by Public Health, sponsored by the Child Death Overview Panel

and involved a multi-agency group, including consultation with the Lullaby

Trust. The film is hosted on the Norfolk County Council website, with a

link from the aforementioned ‘Just One Norfolk’ website. Campaigns were

run in July, August and December 2018, with targeted advertising using

SkyAdSmart and Facebook. It is intended that there will be a further

campaign in spring 2019 to coincide with Safer Sleep week. Evaluations

have taken place and some adjustments were made following the first

campaign in response to comments received.

5.2.22 It is too early to know whether either of these developments will achieve

their objectives.


Were all necessary assessments undertaken and were they timely,

robust and accurate? Did assessments consider risk and the impact of

newborns on a household? Were past behaviours included in

assessments?

AB1

5.3.1 The decision for Children’s Social Care to undertake an assessment

during the mother’s pregnancy with AB1 was taken at a Child in Need

meeting at 25 weeks gestation. The assessment was started 10 weeks

later and completed three days after AB1 was born. It was authorised by

the team manager 16 days later with a note included that it was

completed within timescales but that there had been a delay authorising it

due to work pressures. The pre-birth protocol now states that:

“it is not acceptable, unless there are compelling reasons, to leave an

assessment until close to the baby’s birth or until after the baby is born.

14 Ibid 15 Ibid 16 Ibid

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Professionals must ensure that they use the antenatal period to gather

information and assess risk and plan to mitigate risk.”

5.3.2 It is a matter of great concern if, as the assessment states, there was no

consultation with the father in the course of undertaking the assessment.

He was living in the family and had previously been treated as the key

person for keeping the family safe following the mother’s psychosis. He

remained a significant part of the children’s care network.

5.3.3 In undertaking the assessment, the social worker consulted with the

health visitor, GP, mother’s community psychiatric nurse and mother’s

drug worker all of which were appropriate. The midwife did not contribute

directly to the assessment as she was unavailable but the social worker

accessed her notes. Working Together to Safeguard Children 2018

states that where concerns relate to an unborn child, the involvement of

midwifery is vital. This is reflected in a new version of the pre-birth

protocol, introduced by Norfolk Safeguarding Children Board on 17

October 2018. There is also no evidence that the Family Support Worker

contributed to the review, which is a concern given her significant level of

involvement.

5.3.4 The assessment suggests that both parents had engaged well with

Norfolk Recovery Partnership although records elsewhere indicate that

the father had not engaged since his community order ended several

months previously. Nevertheless, a concern is expressed that he had lost

his motivation and gone back to alcohol. The father did have a drug

worker at the time the assessment was undertaken but there is no

indication that the drug worker was consulted.

5.3.5 The voices of the older children are not heard within the assessment;

there was no consultation with them or the schools they attended and

their life experiences were not explored. It is stated that the maternal and

paternal families are emotionally available to the family and specifically

refers to support from the maternal grandmother and the father having

spent some time at the paternal grandmother’s during the pregnancy

when he experienced difficulties with his mental health. However, the

social worker does not appear to have involved the grandmothers, or any

other members of the extended family in the assessment. After AB1’s

death, it was determined that the children should not stay with the

paternal grandmother due to concerns about her lifestyle.

5.3.6 Notwithstanding the above shortfalls regarding who was consulted, the

assessment accurately identifies substance misuse by both parents and

the unsatisfactory housing situation as key risk factors for the family.

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However, it appears to have minimised the extent to which the father

started drinking again and did not consider the likelihood of the mother

regressing with regards to substance misuse if the father was doing so. It

also did not consider the possible impact on the mother’s mental health of

having another baby.

AB2

5.3.7 The referral from the Police, which led to the first assessment undertaken

by Children’s Social Care in relationship to AB2’s family, was triaged by

the MASH team two days after the Police attended the incident. This was

outside the target time of 24 hours, which is not an uncommon occurrence

due to the number of domestic abuse notifications being submitted by the

Police. This remains a challenge, particularly at the beginning of the

week as a backlog of referrals often builds up during the weekend.

5.3.8 Following the MASH triage there was a gap of 15 days before contact was

made with the family. This was due, in part at least, to the mother having

changed her phone number, and phone calls therefore going unanswered.

The assessment was not completed until four months after the referral

was made and 3½ months after the first contact with the family. This is

significantly outside the expected timescale of 35 working days. It was

recorded as being due to the social worker responding to priority duty

matters and additional cases as a result of the pressure of work.

5.3.9 The manager’s decision, written prior to the social worker starting the

assessment, noted the previous social work assessment and other

notifications received from the Police. However, the work plan did not

make specific reference to the need to explore the father’s alcohol use,

despite this being a consistent theme in the previous domestic incidents.

5.3.10 Although all family members were given the opportunity to contribute to

the assessment there appears to have been no discussion with either

parent about alcohol use, how this impacts on them or whether the father

needed any help controlling his alcohol use. There is a statement that

‘one alcohol fuelled argument’ had had such major repercussions and

another that states that for the parents, “the argument (alcohol fuelled)

was quickly forgotten.” This minimises the apparent part that alcohol had

played in a series of previous incidents and the potential seriousness of

such incidents. The father now acknowledges that alcohol use was a

problem to him at that time. However he was not willing to admit this to

the social worker because he was worried that it would result in his

children being removed. The assessment should have been more

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rigorous, using the information available from the Police notifications to

challenge the parents regarding alcohol use.

5.3.11 The impact of the overcrowding was not addressed in the social care

assessment and the fact that another child was due which would make

this situation worse. The mother described the father as a good provider

as the breadwinner for the family. In fact the family had debts and rent

arrears and the history of police interventions shows that money was a

contributory factor in some of the domestic incidents.

5.3.12 The mother was not pregnant when the referral was made to Children’s

Social Care and therefore her pregnancy did not feature in the work plan.

The assessment makes reference to the mother being eight weeks

pregnant although it is not clear how the social worker became aware of

this. The assessment does not consider the parents’ views about this or

the potential impact of another baby on the household. The previous

cluster of domestic incidents referred to in paragraphs 4.3.1 and 4.3.2

occurred towards the end of the mother’s previous pregnancy and in the

weeks immediately after Sib3(2)’s birth. It would therefore have been

appropriate to have explored any possible links. The social worker did not

make any contact with Midwifery Services to involve the midwife in the

assessment or make the midwife aware of the history.

5.3.13 As with AB1, because there was a child in the family who was under five

years of age the social worker should have undertaken a joint assessment

visit with the health visitor but this did not take place. A duty worker in

Children’s Social Care contacted a duty worker in the Health Visiting

Service before the assessment commenced to request information about

the family. However, there is no evidence that the social worker

undertaking the assessment contacted the Health Visiting Service and

certainly there was no contact with the allocated health visitor, who

remained unaware that the assessment was being undertaken. The

Police, schools and children’s centre contributed to the assessment.

5.3.14 During the course of the assessment, a Rapid Network meeting17 was

held and a unanimous recommendation made for Children’s Social Care

to end their involvement and for the children’s needs to be met by school,

children’s centre and health. This meeting was attended by the mother,

Sib2(2)’s father and step-mother, and representatives from Children’s

Social Care, Sib2(2)’s school and the children’s centre. The Health

Visiting Service did not know about this meeting and was not invited to

17 A Rapid Network meeting is a meeting that can be convened when using the signs of safety approach. It is used to support decision making where there are concerns for the immediate safety of a child. The meeting involves key family members and professionals.

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attend. The father did not attend and it is not known whether he was

invited.

5.3.15 The assessment itself was not finished until 5½ weeks after the Rapid

Network Meeting. The ‘Factors Identified at the End of the Assessment’

section requires the assessor to answer yes or no to a series of possible

concerns in relation to the children, parents and other household

members. In this assessment every possible concern has been given the

answer ‘no’, including concerns about alcohol misuse and concerns about

domestic abuse. The assessor acknowledged that the incident had been

‘emotionally harmful’ with ‘excessive alcohol consumption involved’ but

the assessor was satisfied that this was not a true representation of how

the parents function. It is not clear how the assessor reached this

conclusion given the absence of exploration of alcohol use and the

previous incidents. There is no consideration of the previous social work

assessment when the parents had stated that too was 'a one-off' incident

or that the mother had previously minimised incidents and changed her

statement. The manager’s overview within the assessment concurs with

the assessor’s analysis. The outcome of the assessment was no further

action from Children’s Social Care as the parents did not want Children In

Need support or a Family Support Process.

5.3.16 A Cause for Concern Notification was submitted by the midwife to the

Midwifery Safeguarding Team when the mother was 12 weeks pregnant.

20 days later, as a result of receiving the Cause for Concern notification,

the Midwifery Safeguarding Team contacted Children’s Social Care to

ascertain whether or not the family was an open case. The response from

Children’s Social Care was that the family was not an active case and

there was no information to give. Records show that Children’s Social

Care completed their assessment and closed the case in-between the

Cause for Concern Notification being written and the Midwifery

Safeguarding Team making contact. It would have been appropriate for

Children’s Social Care to have provided information about the recent

involvement but this did not happen and the midwife and health visitor

remained unaware of the involvement. In addition, the midwife and health

visitor liaised regarding the pregnancy one day after the social work

assessment was completed. If the health visitor had been involved in the

Children’s Social Care assessment, as should have been the case, she

would have been able to make the midwife aware of it.

5.3.17 At the time the midwife submitted this Cause for Concern Notification, the

process was to send them by post to the Midwifery Safeguarding Team;

they are now sent electronically. This does not fully explain the time lag

between the notification being sent and contact being made with

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Children’s Social Care but may account for some of it. The Midwifery

Safeguarding Team now contact individual social work assessment teams

when making enquiries and it is considered by agencies involved that this

has resulted in better information sharing.

5.3.18 The second social work assessment that was undertaken in respect of

AB2’s family resulted from a referral from the school which Sib1(2) was

attending. The assessment referred to the possible impact of some

historical issues relating to Sib1(2). It also referred to the mother

(Sib1(2)’s step mother) being heavily pregnant and feeling exhausted and

undermined by the father.

5.3.19 The assessment action plan included the need to explore the situation

with all members of the household, Sib1(2)’s mother and key

professionals. Reference was made to the unborn child and the need to

arrange a joint visit with the health visitor in view of there being a child

under five years of age in the household. However, the references in the

referral to the mother feeling exhausted and undermined by the father do

not appear to have been considered and the plan does not include any

requirement to see the mother without the father.

5.3.20 All of the children in the family were opened for assessment but the

assessment that was undertaken focused almost entirely on Sib1(2),

rather than the whole family. By the time the social worker commenced

the assessment, Sib1(2) had gone to stay with his mother in a different

part of the country. Although at the time it was intended that this would be

a short-term arrangement, Sib1(2) ended up remaining with his mother

and the social worker never met him.

5.3.21 At the beginning of the assessment, the social worker did contact the

health visitor to discuss the referral but the mother said that she did not

want a joint visit. Because the focus was entirely on Sib1(2) without any

significant consideration of Sib3(2), the social worker did not press this

matter and the joint visit did not take place. Although it was noted that the

mother was pregnant, no contact was made with the midwife. Similarly

there was no contact with other relevant agencies such as the GP

practice, children’s centre or the school attended by Sib2(2).

5.3.22 Although the father indicated to the social worker that the overcrowded

home was affecting his drinking, this was not explored further. Instead it

was recorded in the assessment that the parents stated that alcohol

misuse and domestic abuse were in the past. Once it was known that

Sib1(2) was going to remain with his mother the assessment was closed

by Children’s Social Care.

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Were actions timely and consistent with assessments undertaken and

decisions made?

5.4.1 Actions taken were generally consistent with assessments undertaken

and decisions made. However, paragraph 3.8.1 describes a delay of 10

months between the mother of AB1 being assessed by Assessment and

Focused Intervention in September 2015 and the provision of a service in

July 2016. This is significantly outside the accepted waiting time of 15

weeks. In part this delay was due to a four month gap between the

assessment being undertaken and the resulting referral being forwarded

to the Community Mental Health Team. This was subject to an internal

investigation by Norfolk and Suffolk NHS Foundation Trust which has

been unable to establish the reason for this delay as the assessor has left

the service.

5.4.2 Once the referral was received by the Community Mental Health Team

the referral was placed on a waiting list which is routine practice due to

the numbers of referrals received. Initially, AB1’s mother was on a waiting

list for those with the lowest level of need. People on this list should

receive monthly wellbeing calls to ensure that those who developed a

priority need were allocated to a care co-ordinator. The mother only

received two wellbeing calls in a five month period; the second of these

established that she was pregnant and she was prioritised for allocation

because of this. It is not known why welfare calls were not undertaken

every month as they should have been.

5.4.3 There was a delay of six months between the referral belatedly being sent

to the Community Mental Health Team and the mother starting to receive

a service. The service would not have been provided at that time if the

mother had not been pregnant. Therefore, even if the referral had not

been delayed the accepted waiting time of 15 weeks would not have been

met.


Was there appropriate supervision and management oversight of

assessments, decision making and action taken?

5.5.1 Regular supervision of the social worker is recorded in the records for

AB1’s siblings but there appears to have been insufficient guidance and

challenge with regard to the assessment that was undertaken. The

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assessment includes a brief summary of concerns from the manager

which provides a rationale for the decision to undertake an assessment

but it does not include a detailed work plan. The manager’s comments on

the final assessment are also very brief and do not challenge any of the

shortfalls with the assessment that are identified in section 5.3 above.

They are inconsistent with the record of a supervision session during the

course of the assessment where it was recorded that whilst the mother

had engaged well with mental health, Norfolk Recovery Partnership and

GP, the father’s mental health was dipping and there was some alcohol

misuse. In this supervision the manager noted some concerns with how

the mother would cope with a new baby.

5.5.2 Regarding the first social work assessment in respect of AB2, the day one

work plan was very generic and not focussed on the family.

Subsequently, supervision did take place but again there was insufficient

challenge of the assessment by the manager. There is no evidence that

the manager identified or challenged the shortfalls in the assessment that

are identified in paragraphs 5.3.2 to 5.3.5 of this report.

5.5.3 It is acknowledged by Children’s Social Care that at the time the first

assessment was shut down there was a problem with oversight and

decision making at management level in the social work team that was

dealing with this case. Children’s Social Care now holds regular

workshops around this issue and that of professional curiosity.

5.5.4 The second assessment relating to AB2 was undertaken by a recently

qualified, and therefore inexperienced, social worker. The day one plan,

provided by the manager to guide the social worker, included actions

relating to the whole family but did not explicitly refer to the need to

explore concerns around domestic abuse and alcohol misuse. It directed

the social worker to “speak to other professionals including health and

education” but was not specific as to who should be spoken to. It was not

clear that there should be contact with both schools being attended by

children in the family, that there should be a joint visit with the health

visitor because there is a child under five or that there should be contact

with maternity services as the mother was pregnant.

5.5.5 The social worker who undertook the assessment worked in the Norfolk

Institute for Practice Excellence (NIPE) team. This was a small team of

newly qualified social workers who were undertaking their Assisted and

Supported Year in Employment. Social workers in the team worked

closely with a team manager and assistant team manager and received

regular caseload supervision and weekly group supervision. Supervision

in respect of this case focussed on Sib1(2) to the exclusion of the wider

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family. Once Sib1(2) left the family it was a management decision that the

threshold for an assessment was no longer met. The management

overview suggests the manager’s opinion was that the wider family

problems were a result of Sib1(2)’s behaviour problems. This view

appears to overlook the concerns around the father’s behaviour and the

possible impact of this on the younger siblings and unborn baby. Instead

of challenging the way the assessment focused on just one child, the

manager’s overview reinforced this practice.

5.5.6 At the time of this assessment Children’s Social Care had moved from

initial and core assessments to a single assessment and there was

considerable discussion taken place about proportionality. It is believed

that this may have influenced the manager’s decision making.

5.5.7 The Family Support Workers who worked with AB1’s family received

monthly caseload supervision and the health visitors received 12 weekly

supervision. No concerns have been identified with the supervision

received in these cases.

5.5.8 Within the Norfolk and Norwich University Hospital NHS Foundation Trust

Midwifery Service, community midwives receive safeguarding supervision

but, at the time of events considered in this review, the specialist

(perinatal) midwife with responsibility for safeguarding did not do so. This

has been addressed and safeguarding supervision is now provided to the

perinatal midwife.

5.5.9 The drug workers from Norfolk Recovery Partnership received regular

supervision from the team manager but the emphasis was on forms

completed and key performance targets which may have been at the cost

of considering the quality of the service delivered. There is a record that

the decision to discharge the father from Norfolk Recovery Partnership

was made following consultation with the manager. This review has not

been provided with a record of any management input into the decision to

discharge the mother.


How effective was inter and intra-agency communication, sharing of

information and joint planning? Were there any significant gaps?

5.6.1 This review has identified examples of good information sharing and joint

planning in these cases but also occasions where this did not happen.

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5.6.2 Several different services were involved with the family of AB1 during the

period under consideration. This included, at various times, social work

services, family support, health visiting, midwifery, GP, Norfolk Recovery

Partnership drug workers for both parents, Norfolk Recovery Partnership

counselling for the mother, Community Mental Health Team for the

mother, probation for the father, housing provider, local authority housing,

housing support and three schools. The Child in Need meetings should

have provided a regular forum for relevant practitioners to meet with the

parents and with one another to share information and plan. It is positive

that these meetings did take place on a regular and frequent basis

throughout the period.

5.6.3 The minutes of the Child in Need meetings should include a record of who

has been invited to and who has attended the meetings. This information

has not been accurately filled in for the meetings regarding this family and

therefore it is not clear who attended each meeting.

5.6.4 As far as the Lead Reviewer can ascertain, one allocated social worker

was present at all the meetings and there also seems to have been good,

consistent attendance from one named health visitor and the two family

support workers who were involved at different times. There was no

representation from the housing provider or the Local District Council

Housing and no indication that they were ever invited to the meetings.

Considering the significance of the housing situation for the family this

appears to have been a major omission. Neither the midwife nor the GP

were invited to the meetings. The GP would be unable to attend a

monthly Child in Need meeting but a monthly meeting is held with the

health visitor to discuss all cases on the safeguarding list and the family

was on the list during the time under consideration. The GP was also

aware of the mental health support that was in place for the mother.

5.6.5 Of the three schools involved, two were represented at the majority of

meetings during the period when children from the family attended the

school. The third school attended meetings up until March 2016 but did

not attend subsequent meetings. It appears that this situation arose

because the member of staff who had attended left the school and

information about meetings was not passed on to anyone else. In

September 2016, the social worker wrote to the school stating that no-one

had been attending from the school. Children’s Social Care should not

have waited over five months to follow up the school’s attendance and

equally the school should have enquired about Child in Need meetings if

they were not invited.

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5.6.6 Drug workers, counsellors, probation and housing support are all

referenced in the minutes of some Child in Need meetings. Due to

incomplete recording referred to in paragraph 5.6.3, the Lead Reviewer

has been unable to ascertain whether they were all invited to attend and

which did attend. However, there are instances in the Child in Need

meeting minutes where the lack of recording of progress relating to

specific action points, particularly around the parents’ engagement with

Norfolk Recovery Partnership indicates that no-one at the meeting was

able to provide specific information. This suggests that the relevant

professional was not present and had not provided a report.

5.6.7 It was identified at the learning event that the date of the next Child in

Need meeting will often be agreed at the end of the previous meeting and

will be recorded on the minutes. However, the minutes are often not

distributed until the next meeting. Therefore, if someone misses a

meeting they may not be informed of the date of the next meeting unless

they make a point of asking. This could be prevented if, after a Child in

Need meeting, a notification was sent to all members of the group

informing them of the next meeting date. Equally, if a practitioner knows

they have missed a Child in Need meeting they could proactively request

the date of the next meeting. It is likely that similar situations arise with

other types of multi-agency meetings.

5.6.8 It has become evident from the information collected for this review that

due to the number of agencies involved, the mother was expected to

attend numerous appointments, sometimes including two or three on the

same day. Some of these involved practitioners attending the family

home but others involved her going elsewhere. Better planning and co-

ordination between agencies could have gone some way towards

alleviating this situation. Some of this could have been done in the Child in

Need meetings but it was not identified as an issue at the time.

5.6.9 Consideration could also have been given to whether all the services were

required. In particular it is questionable whether the instigation of services

from the Community Mental Health Team was beneficial given that

Norfolk Recovery Partnership was already providing regular visits from a

drug worker and counselling. The mother’s mental health was considered

to be reasonably strong by the time she was accepted by the service and

she was only accepted due to being pregnant. There appears to have

been no information sharing between Norfolk Recovery Partnership and

the Community Mental Health Team although both were part of Norfolk

and Suffolk NHS Foundation Trust.

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5.6.10 In 2018 Public Health re-commissioned drug and alcohol service in

Norfolk. The contract was awarded to Change Grow Live (CGL), a

national charity, and commenced on 1 April 2018. The Lead Reviewer

has no information to enable an evaluation of the impact of these

changes.

5.6.11 A miscommunication between Housing Services and Children’s Social

Care resulted in a situation where Children’s Social Care thought they had

paid off the whole of AB1’s family’s rent arrears and that they would be

able to move house when in fact there were still arrears to pay. It is not

clear how this misunderstanding arose, especially as earlier Children’s

Social Care records made reference to both parents having arrears.

Better engagement with the Housing Services throughout the Child in

Need process may have avoided this situation arising.

5.6.12 Monthly liaison meetings between GPs and health visitors took place in

the GP Practice where AB1’s family were registered but at the time under

consideration these meetings were not in place at the practice where

AB2’s family were registered.

5.6.13 In section 5.3 of this report, comment is made about the lack of adequate

inter-agency communication during the social work assessments. In

particular there was a significant gap in information sharing which resulted

in the midwife and health visitor being unaware if recent Children’s Social

Care involvement with the family of AB2 around the beginning of the

mother’s pregnancy.

5.6.14 A variety of different IT systems are seen as a barrier to good information

sharing. Not all GP Practices use SystmOne which inhibits information

sharing with health visitors. Norfolk and Suffolk NHS Foundation Trust

and Norfolk and Norwich University Hospital NHS Foundation Trust are

large organisations and different parts of the organisations use different IT

systems.

6. Learning from the Review

6.1 With regard to Safer Sleeping

6.1.1 It is believed to be established practice in Norfolk for midwives and health

visitors to give safer sleeping advice on several occasions during

pregnancy and shortly after a baby is born to the baby’s mother.

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6.1.2 The extent to which the baby’s father or other primary care givers are

given this advice is inconsistent and is not prioritised.

6.1.3 A record of when and to whom this advice is given is not consistently or

routinely documented.

6.1.4 There is no clear evidence that the safer sleeping message is being

actively reinforced by practitioners from agencies other than midwifery

and health visiting. Practitioners from agencies such as Children’s Social

Care and substance misuse services should be reinforcing this message

when working with men and women who have, or will soon have a baby to

care for.

6.1.5 Even when parents are aware of safer sleeping advice they may not

follow it, especially when they have been using alcohol and other drugs.

In families where practitioners have concerns about alcohol and/or

substance use there is a particular need to reinforce the message and to

ensure that families have plans that will minimise the likelihood of co-

sleeping taking place.

6.1.6 In overcrowded houses, where there may be insufficient space for

everyone to have their own bed, it is particularly important to establish

where the baby will sleep and to reinforce messages about co-sleeping.

6.1.7 Nationally, co-sleeping continues to be a factor in a small but significant

number of infant deaths and in the majority of these cases substance use

is a factor.

6.1.8 The Norfolk safer sleeping campaign, including the film, is a positive and

proactive step to increase awareness of the safer sleeping message

across target groups within the population.

6.2 Other Learning

6.2.1 Some practitioners showed good perseverance in helping the mother of

AB1 to engage with services and supported her to attend appointments

and groups. Her engagement was much better when visits were made to

the home or when practitioners helped her to attend. The father may

have engaged better with drug and alcohol services if home visits had

been offered. With difficult to engage families it is important that

practitioners consider how services can be delivered in ways that are

most likely to secure engagement.

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6.2.2 There were some unrealistic expectations on the mother with regard to

appointments. She was involved with a large number of services and

sometimes she was expected to attend two or three appointments in one

day. Child in Need meetings could have been used to help to coordinate

appointments if this issue had been identified.

6.2.3 There was a lack of assertive challenge with the father of AB1 when he

did not engage with services and continued drinking. Practitioners were

over optimistic about his assurances that he would start to engage despite

a lack of evidence that he was doing so.

6.2.4 In both cases there was a lack of engagement with the fathers and it was

left to the fathers to determine their level of engagement without any

expectations being placed on them that they would be present when

practitioners undertook visits. Cultural change is required in child care

agencies so that it becomes the norm to engage with male and female

carers.

6.2.5 An additional complication when involving fathers in maternity care is that

it is appropriate for some contact to take place with the pregnant woman

away from her partner. Nevertheless, it is important that there is

engagement with the father and that they are given information about

keeping the baby safe.

6.2.6 There was also a lack of engagement with the children and the wider

family network, including in social work assessments. As a result,

opportunities to elicit support and better understand risk were missed and

the children’s experiences of living in these families were not explored in

detail.

6.2.7 Parental drug use remained hidden with regard to AB2’s parents and the

mother’s statements that the father was no longer drinking to excess were

accepted at face value. Professionals need to demonstrate professional

curiosity and should seek to gather information from a variety of sources

rather than relying on self-reporting. Professional curiosity is one of four

key learning areas within Norfolk Safeguarding Children Board’s thematic

learning framework.

6.2.8 The addition of a new baby in a family can be a source of stress and can

increase a family’s vulnerability. Furthermore, mothers who have

abstained from substance use during pregnancy to avoid harming the

unborn baby may resume such use after giving birth. Agencies should be

extremely cautious about withdrawing services shortly after a baby is

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born. They should not do so without reassessing the situation, including

face to face contact with the service user.

6.2.9 It is best practice for social workers to undertake a joint visit with the

health visitor when undertaking an assessment of a family with a child

under five years of age. However, this practice was not followed in any of

the assessments undertaken in this case.

6.2.10 The pre-birth assessment of AB1 was not completed by the time he was

born and the first social work assessment of AB2 was late being started

and not completed within 35 working days. All three social work

assessments contained significant gaps in the analysis and did not

consider the likely impact of a baby on the family. There was

management oversight on all these assessments but this did not identify

the shortfalls. Use of the Norfolk Local Assessment Protocol should help

to address these shortfalls.

6.2.11 Children subject to child in need planning are often experiencing life in

high risk environments. In light of this the Child in Need process must

replicate that of any other statutory process. Incomplete and inconsistent

attendance of practitioners at Child in Need meetings inhibited agencies’

ability to fully measure what progress was being made in AB1’s family

because clear and accurate information was not available. This

contributed to insufficient challenge over non-engagement and over

optimism about the progress being made. In addition, because the action

points in the Child in Need plan were not SMART agencies could not

clearly measure progress. Children’s Social Care report that over the past

two years, considerable work has been undertaken to improve the quality

of Child In Need plans. Practice Standards are in place and regular audits

are undertaken. Audits suggest that progress is being made although

there is still room for further improvement.

6.2.12 Shortfalls occurred in communication within and between organisations

involved with these families. In both cases there was a lack of

communication with the housing provider at an early stage in the process.

This might have enabled a better understanding of the families’

circumstances and assisted in addressing the overcrowding. There was

insufficient information sharing between services within Norfolk and

Suffolk NHS Foundation Trust. Both Norfolk Recovery Partnership and

the Community Mental Health Team worked with AB1’s mother but

practitioners from these services did not communicate with one another.

6.2.13 The drug and alcohol service in Norfolk has been re-commissioned since

the events considered in this review. It is important that the new service,

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CGL, is aware of the learning from this review and that appropriate

arrangements are in place between CGL and agencies working with

children and families.

7. Recommendations

1. Norfolk Safeguarding Children Board should review and re-launch the

‘Safer Sleeping Guidelines for Professionals’.

• Relevant partner agencies should ensure that appropriate staff are

familiar with the ‘Safer Sleeping Guidelines for Professionals’ and

are adhering to these when working with families where there is a

pregnancy or a baby under 12 months of age.

• Relevant partner agencies should ensure that agency policies and

procedures are consistent with the revised ‘Safer Sleeping

Guidelines for Professionals’.

2. Norfolk Safeguarding Children Board and partner agencies should

continue to evaluate the impact of the film regarding safer sleeping to

inform decisions as to how it should be used in the future.

3. Norfolk Safeguarding Children Board and partner agencies should

evidence how they will promote a culture change regarding the

importance of agencies engaging with all significant carers when

working with families.

4. Cambridgeshire Community Services should ensure that

fathers/partners are specifically invited to be present at the antenatal

visit and new birth visit and evaluate the outcomes.

5. Norfolk Safeguarding Children Board should seek reassurance that

the partner agencies with roles and responsibilities in respect of

unborn children are effectively implementing the Norfolk Pre-Birth

Protocol when working with women and girls who are pregnant.

6. Children's Social Care should ensure that assessments are suitably

robust, comprehensive and analytical with high quality managerial

oversight. They should be conducted in accordance with all aspects

of the Norfolk Local Assessment Protocol, using the Framework for

the Assessment of Children in Need and their Families (as set out in

Working Together 2018), underpinned by the Signs of Safety

Approach. Assessments should include contributions from partner

agencies and where the family contains a child under five years of

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age a joint visit by the social worker and health visitor should be

undertaken.

7. Children’s Social Care should ensure that the Child in Need process

replicates that of any other statutory process and that equitable regard

is paid to children subject to Child in Need planning. This must be

evidenced in supervision and management overview records.

Additionally, there must be clear evidence of who was invited to Child

in Need meetings, who attended, clear actions and timely minutes of

the meeting.

8. Agencies who work with children and families should ensure that

when practitioners are working with a family who lives in social

housing and their housing situation is a source of concern, contact is

made with the housing provider at an early stage.

9. Norfolk Safeguarding Children Board should develop links with CGL

to ensure that:

• The learning from this review is shared with CGL;

• Working relationships are developed between CGL and agencies

working with children and families.

norfolk safeguarding children board serious case review ...€¦ · of ab1 and the father of ab2...

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