I
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Background
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1.1
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CHILD F was a baby who
died very shortly after
his mother moved to Leeds. The
mother was young and never
had a stable home situation,
moving between homes of
family members, friends,
and temporary accommodation
of her own. It was discovered
that there had been previous
Social Services concerns
about an older sibling. A
grandparent was a Schedule
I Offender.
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1.2
|
In the light
of this history, and
the nature of the child's
death, it was decided that
Leeds ACPC would undertake
a Serious Case Review under
the terms of "Working Together".
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II
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The Terms of
Reference and Purpose
of the Review
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2.1
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The overlying purpose
of a Serious Case Review
is set out at Chapter 8
of Working Together to
Safeguard Children; "When
a child dies, and abuse
or neglect are known or
suspected to be a factor
in the death, local agencies...
should consider whether
there are any lessons to
be learned from the tragedy
about the ways in which
they work together to safeguard
children.."
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2.2
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Specifically agencies
should; · Establish
whether there are lessons
to be learned from the
case about the way in which
local professionals and
agencies work together
to safeguard children;· Identify
clearly what those lessons
are, how they will be acted
upon, and what is expected
to change as a result;
and as a consequence · To
improve inter-agency working
and better safeguarding
children.
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III
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Recommendations for Individual
Agencies
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3.1
|
Police (Local Authority
2 Area and West Yorkshire
Police Service)
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3.1.1
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The Police do not routinely
make enquiries to the Child
Protection Register through
the Social Services Department,
especially out of hours,
either in Local Authority
2 area or West Yorkshire,
when dealing with a case
that might indicate significant
harm. The Police need
to be reminded of the requirement
of doing so as per ACPC
Procedures.
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3.2
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Health Service
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3.2.1
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A record keeping
audit within midwifery,
health visiting and A & E
to be undertaken to identify
areas where practice
needs to be improved. Each
agency to review record
keeping protocols (and
relevant and related
training) for staff and
to re-undertake audit
6 months after protocols
revised to ensure adherence
to same.
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3.2.2
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Midwives to receive
training related to the
importance of observations
and recording of the
mother/child relationship
and social circumstances
as part of their holistic
obstetric assessments.
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3.2.3
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Named nurses and doctors
in each Health Trust to
work with health service
managers to identify appropriate
management/supervisory/induction
mechanisms to ensure staff's
understanding of: (i) child
protection work being a
multi-agency responsibility;
(ii) raising the awareness
of staff that they have
a responsibility to question,
challenge and influence
decision-making processes
in relation to children
in need and child protection;
(iii) functions of the
Child Protection Register;
and (iv) working with families
where engagement is difficult. Staff
should be reminded that
referrals should be followed
up within 48 hours.
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3.2.4
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Each Health Trust to consider
the procedure to be undertaken
when a parent refuses to
give consent for the Guthrie
test, specifically when
the refusal does not appear
to be based on a consideration
of the health needs of
the child.
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3.2.5
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The Overview Panel considered
the recommendation from
the Leeds Internal Management
Report, which states: "When
new born infants are discharged
from hospital to an address
outside the area of their
registered GP, there should
be a local GP identified
for the period in question
and that sufficient information
should be made to that
GP regarding the child's
social circumstances"
The Overview Panel considered that
there are already protocols in place
nationally which ensure care is provided
for patients residing outside of
their normal GP catchment area and
that this case proved they work,
as maternal aunt's GP attempted to
visit the home and is likely to have
been appraised of the social circumstances
by the community midwife who requested
this view. The Overview Panel does
not, therefore, endorse this recommendation.
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3.3
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Local Authority 2 Social
Services Department
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3.3.1
|
There must be a timely
assessment of the policy
of children's referrals
and appropriate response
to service users and referrers. (This
has been addressed by a
review of the staffing
levels and management of
the SSD teams concerned).
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3.3.2
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In all cases where an
assessment is required,
and all cases where Section
47 enquiries are initiated,
children and appropriate
family members must be
seen as part of the process,
and cases not closed until
the assessment has been
completed.
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3.3.3
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All visits to families
must be recorded, identifying
the purpose of the visit,
and the outcome of the
visit, as required by case
recording procedures.
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3.3.4
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Where prescribed timescales
for convening a Child Protection
Conference are not complied
with, the reason for this
should be recorded.
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3.3.5
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The Social Services Department
should ensure that appropriate
staff are aware of national
and local child protection
procedures and guidance
and adhere to this. (This
has been addressed by revised
supervision arrangements,
and arrangements for training)
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3.4
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Leeds
Social Services Department
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3.4.1
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All contacts/referrals
to be recorded as per recording
policy.
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3.4.2
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If Initial Assessment
is passed from one office
to another, the initial
timescales still apply.
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3.5
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Recommendations
for ACPC
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3.5.1
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All
agencies to have in place
systems that facilitate
referral to Designated
Professionals, or equivalent,
when practitioners have
concerns about the actions
of other agencies during
child protection enquiries,
to ensure that concerns
can be resolved at an
appropriate management
level.
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3.5.2
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Any decision to cancel
an Initial Child Protection
Conference will only take
place in consultation with
those agencies involved
in the initial decision
to convene the Conference.
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