CYSCP

Background

Jenny is an infant who attended Hospital presenting with symptoms of possible febrile convulsion (fits). However, after further medical investigation, clinical staff became concerned for Jenny as she had reduced movement in the left side of her body. A CT scan was completed which showed a subdural hematoma (bleed on the brain) and subsequent ophthalmology tests revealed bilateral retinal haemorrhages. The medical view was that these injuries were highly suspicious of non-accidental injury.

Neither mother nor mother’s partner could offer an explanation for the injuries that Jenny had sustained and were subsequently arrested.

Due to the significant injuries Jenny sustained, this case was referred to the National Panel by the local authority, and the CYSCP instigated the Rapid Review Process which explored the following themes to identify areas of good practice and learning:

• Domestic Abuse
• Managing Allegations Against Professionals/People in Positions of Trust
• Engagement of Father/Partners
• Response to a previous 999 call and attendance at A&E
• Parental Mental Health

The Family

Jenny has a loving wider family network who she enjoys spending time with. At the time of the Rapid Review, it was understood that Jenny lived with her mum and her half-brother. Jenny has had limited contact with her father due to the relationship breakdown between her parents. Her half-brother has had no contact with his father due to domestic abuse perpetrated by his father to their mother. Jenny’s mother had been in a new relationship since Jenny was 3 months old. Her new partner worked shifts and on his days off he would spend his time with Jenny, her mother and half-brother.

Voice/Lived Experience of Jenny

If Jenny were able to speak to communicate her needs and feelings, the reviewers hypothesised that Jenny would say that, in order to feel safe and loved, she needs to live in a warm and secure home environment surrounded by people who love and care for her and prioritise her needs.

During her time on the Children’s Ward, staff who cared for Jenny shared that ‘she enjoys cuddles, having a story read to her, interacting with the nurses and her carers and being visited by people who love and care for her’. Jenny responds to warm and engaging voices with smiles and is reaching for toys and trying to stand with support. Jenny is a happy, smiley and sociable little girl’.

What areas of good practice was highlighted?

The following areas of good practice were identified as part of the Rapid Review process:

• The midwife in the Early Pregnancy Unit accessed mother’s electronic patient record and identified a domestic abuse flag. This prompted the midwife to contact Hospital Safeguarding Children Team, who reviewed the Multi-Agency Risk Assessment Conference (MARAC*) minutes and shared the relevant information with the midwife and advised that a cause for concern form (hospital safeguarding documentation) should be completed on booking of pregnancy with the midwifery team. * A MARAC, or multi-agency risk assessment conference, is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors.
• At the booking appointment the midwife asked routine domestic abuse enquiry questions and Jenny’s mother shared with the midwife the history of domestic abuse with her previous partner (father of Jenny’s half-brother), the restraining order and shared details of her new partner. Jenny’s mother did not disclose any concerns regarding domestic abuse in relation to her new partner.
• The Police PPN (A PPN is an information-sharing document that records safeguarding concerns about an adult or child. PPNs are shared with partner agencies to inform a multi-agency response was shared with IDAS (a charity offering Domestic Abuse services), Healthy Child Service (Health Visiting), Midwifery and Children’s Social Care.
• North Yorkshire Police Domestic Abuse Officer liaised with City of York Housing Team and the Maternity Team at the Hospital and shared information about the concerns about Jenny’s mother’s ex-partner.
• MARAC information sharing processes were followed enabling partner agencies to add alerts onto their records indicating that Jenny’s mother and half-brother were victims of domestic abuse. (Note this system was extended in 2018 in the City of York to include GP's).
• On all occasions North Yorkshire Police referred Jenny’s mother to IDAS for support.
• The Midwife and Health Visitor did ask about Jenny’s mother’s partners and tried to gain an understanding of her relationship status.
• The Health Visitor liaised with Midwifery Services in the antenatal period to promote early care on the basis of Jenny’s mother’s previous mental health problems and of her experience of domestic abuse from her ex-partner. As a result of this liaison, Jenny’s mother was offered a face-to-face antenatal appointment with the Health Visitor.
• Throughout pregnancy and during the post-natal period both the Health Visitor and Midwife monitored Jenny’s mother’s Mental Health and levels of anxiety using various tools (GAD – General Anxiety Disorder Questionnaires/PHQ's – Patient Health Questionnaires). Both the Midwife and Health Visitor signed posted Jenny’s mother appropriately to support services.

Key Learning Points

The following multi-agency learning points were identified as part of the Rapid Review Process:

Learning Point 1

The CYSCP to seek assurance from all agencies that fathers/partners names including date of birth and addresses are recorded within agencies records particularly in relation to domestic abuse enquiries.

Learning Point 2

NHS Foundation Trust to review their documentation standards in relation to this specific case, the current Trust requirements and whether there are any training needs within the Emergency Department or more widely within Paediatric settings regarding documentation standards.

The Trust to also consider incorporating the learning from this case into future teaching sessions to highlight the importance of detailed documentation of injuries to children, and the significance of assessing and documenting a child’s developmental stage in order to inform any safeguarding assessment in relation to injuries to non-independently mobile children.

Learning Point 3

Healthy Child Service to consider the viability of reviewing all attendances under 1 year of age to better target advice and support at the mandated 1-year review.

Learning Point 4

NHS Foundation Trust and Ambulance Service will undertake a deep case file review on the management of the incident with a focus on safeguarding and injuries to under 1's. Any learning from these case file reviews will be shared within the individual organisations and across the City of York Safeguarding Children Partnership.

Learning Point 5

Primary Care to ensure they consider the risks of stopping/continuing anti-depressant medication in pregnancy and to be aware of where they can access guidance regarding this i.e. perinatal team.

Learning Point 6

Primary Care to consider follow up/review requirements for a patient started on anti-depressants in line with NICE guidance and taking into account individual risk factors.

Next Steps

• A multi-agency action plan has been produced and monitored by the Case Review Subgroup