This Serious Case Review was carried out by Independent Reviewers Dr Deborah Stalker and Karen Tudor in September 2019.
Events Leading to this Serious Case Review
1. In the summer of 2018 a twelve week old baby was taken to hospital by ambulance following an emergency call by his father. On examination he was found to have severe brain injuries indicative of non-accidental injury which were likely to be life changing. For the purpose of anonymity the baby is known as Baby F.
2. Given the nature of the injuries, a Child Protection investigation began and Care Proceedings were initiated to ensure the baby was protected. At the time of writing a criminal investigation was underway. A Finding of Fact hearing had concluded that the baby’s father was responsible for Baby F’s injuries.
3. The Local Safeguarding Board carried out a Rapid Review which concluded the case met the criteria for a Serious Case Review. The recommendation was endorsed by the National Safeguarding Practice Review Panel.
 Finding of Fact Hearing is a type of court hearing that considers evidence surrounding allegations of child abuse. It can be used in the family court to determine whether the alleged incidents happened and who might have been responsible. The Family Court is not a criminal court and cannot prosecute parents, findings are based the balance of probability and reported by a family Court Judge. The findings can be used by other agencies to inform planning for children.
 Rapid Review – Safeguarding Boards are required to undertake a Rapid Review into all serious child safeguarding cases within fifteen working days of becoming aware of the incident.
 The National Safeguarding Practice Review Panel decides if a Serious Case Review (WT 2015)/ Local Child Safeguarding Practice Review (WT2018) is required and informs the local LSCB/Partnership of their decision.
4. Following the publication of Working Together 2018, the Local Safeguarding Children Board was moving towards new arrangements which were not yet published at the time this Review was commissioned. The Serious Case Review (SCR) sub-group decided on the method for the review and independent authors from the agencies involved in the care of Baby F were asked to provide written reports addressing specific lines of enquiry. These were:
- “How prior knowledge (of the family) held by agencies is used and weighted in decision making
- The degree of understanding of pregnancy as a period of increased risk of domestic abuse
- What are the barriers to constructing a cumulative picture of risk to the unborn child?
- What inhibits practitioners from challenging colleagues in their own and partner agencies when there are concerns about appropriate decision making?
- Are we gathering comprehensive information/intelligence from each agency involved in order to formulate the correct outcome of decision making?
- How can we ensure there is adequate exploration and analysis of the family network and consideration of family dynamics in decision making around whether the family are able to provide protection and support for the parents and the child?”
From Terms of Reference 11.04.19
5. Two Independent Reviewers were commissioned and the Review covered a period of about 8 months, six months of the mother’s pregnancy and the six weeks leading up to the discovery of the baby’s injuries. Conversations were held with the agency review authors and practitioners. Learning was identified through the practitioner discussions and was considered in the light of current research and relevant evidence from other Serious Case Reviews.
6. The risk of hindsight bias was discussed at both the briefing for agency review authors and the practitioner meeting.
7. Reports of agency involvement were requested from:
- Health Visiting
- Children’s Social Care
- Secondary Care (Health)
- Perinatal Mental Health Service
Family Participation in the Review/Parallel Proceedings
8. Family participation in reviews can provide a useful contribution to the review and subsequent learning. Baby F’s family were invited to contribute but did not respond.
9. For the purposes of anonymity the family members are referred to as follows:
- Baby F – Subject of review
- Ms CM – Baby’s mother
- Mr CF – Baby’s father
- Child OC – Mr CF’s older child.
10. The records state that Ms CM and Mr CF had been together for about five months when Ms CM became pregnant with Baby F. Ms CM was aged 19 years and Mr CF aged 26 years. Ms CM presented to the midwifery services when she was 9 weeks pregnant.
11. Ms CM had had a complex childhood and was known to the Child and Adolescent Mental Health Service (CAMHS) because of a history of self-harming and suicide attempts. CAMHS worked with Ms CM intermittently over 5 years. The records describe Ms CM’s mental health history, including a diagnosis of anxiety and depression.
12. Mr CF was known to Children’s Social Care as he had an older child who had been injured as baby. In 2009, the child, known as OC, had sustained two fractures at the age of 6 weeks. A Finding of Fact Hearing had concluded that one of OC’s parents was responsible for the injuries but was unable to determine which one. Mr CF participated in a therapeutic parenting programme. Nine years later when Baby F was born, Mr CF reported to practitioners that he was having regular unsupervised contact with OC.
13. During the pregnancy the couple were living with relatives as they had no home of their own. They moved several times and just before Baby F was born were living in a hotel. Mr CF had permanent employment.
14. Two months into the pregnancy Ms CM was referred by her GP and by midwifery to the Perinatal Mental Health Service. The service offered Ms CM an appointment but she did not respond. Two months later she was referred again and this time participated in a telephone assessment. This resulted in the Perinatal Mental Health Service attending a pre-birth planning meeting to ensure Ms CM was offered the parenting support she needed after Baby F was born.
15. During the period under review there were two referrals to Children’s Social Care, both from midwifery services during the pregnancy. The first, three months into the pregnancy, was prompted by Ms CM telling midwifery about Child OC’s injuries as a baby, along with concerns about Ms CM’s mental health. This referral led to an assessment which concluded the family could be offered support through the Child in Need framework. However Ms CM declined the offer and, as there were no Child Protection issues identified through this assessment, Children’s Social Care concluded there was no ongoing role for them.
 Child in Need, Section 17 of the Children Act 1989 states that it is the general duty of every local authority to safeguard and promote the welfare of children within their area who are in need; and so far as it is consistent with that duty, to promote the upbringing of such children by their families.
16. The second referral, six months into the pregnancy, related to Ms CM being homeless and her ongoing vulnerability. Children’s Social Care have no record of this referral.
17. Just after the first referral from midwifery, the police were called following an episode of domestic abuse. Ms CM told the Police that Mr CF had “shaken” her. She reported to the Crisis Team (Perinatal Mental Health Service) that Mr CF had violently pushed her and “pinned her down” and she was concerned about her unborn baby. She told them that she was experiencing some suicidal ideation.
 Suicidal ideation – thinking about or planning suicide. Thoughts can range from a detailed plan to a fleeting consideration. It does not include the final act of suicide.
18. At this point Ms CM had left Mr CF and was staying with a relative, who took her to the Emergency Department as Ms CM had abdominal pains. It is unknown whether the Domestic Abuse, particularly in the context of her early pregnancy, was explored at this time.
19. Ms CM later returned to Mr CF and did not wish to pursue the matter.
20. Because of the concerns about the vulnerability of his parents, their homelessness, previous history and mother’s mental health, a pre-birth planning meeting took place. The purpose of the meeting was to ensure adequate support was in place once the baby returned home. The plan included “intensive visiting” by the Health Visitor but because of sickness and holidays, there was no Health Visitor present at the meeting.
21. A plan for an intensive health visiting package had already been agreed with the parents at a home visit made by a Health Visitor prior to the birth planning meeting although this plan for intensive visiting did not happen.
22. Baby F was born in the summer of 2018. He was a healthy baby with weight within normal limits. He was discharged home to the care of his parents.
Baby F at Home
23. Following his discharge from hospital, midwifery saw the baby with his mother at her local clinic on days 3, 5, 7 and 10. Expecting the family to attend visits rather than midwives visiting the home is now common practice partly as a consequence of the rural nature of this area. This is currently under review where families are deemed especially vulnerable.
24. When he was ten days old, in line with usual practice, a conversation took place with Health Visiting and the case was handed over. The Health Visitor planned to see the family the following week.
25. The Health Visitor made a new birth visit during which Ms CM was described as “distracted by the TV.” This Health Visitor knew very little about the family history and did not know that a referral had been made to Children’s Social Care and an assessment carried out, or that there had been a domestic abuse incident when Ms CM was pregnant.
26. Health Visiting had not been present at the pre-birth planning meeting but did know that intensive visiting had been part of the plan and was aware that Ms CM was in touch with the Perinatal Mental Health Service. We were unable to establish whether minutes of the pre-birth planning meeting were available to the Health Visitor.
27. The Health Visitor saw Baby F and both parents twice more and carried out a basic assessment. Nothing of concern came to light, Mr CF is reported to have told the Health Visitor he was not worried about Ms CM’s mental health and Ms CM now declined to participate in the intensive health visiting scheme. As a result, the health visiting services was downgraded to the standard “universal service” and Baby F was injured before they were seen again.
 Universal Service: Health Visitors use an assessment tool intended to provide the practitioner with an indication of the level of service, the “universal service” is what everyone receives, there are 5 visits, ante-natal, new birth, 6-8 weeks, 1 year, and 2 ½ years.
28. In the weeks after Baby F’s birth, despite what Mr CF reportedly told the Health Visitor, both parents contacted their GP asking for help with depression and both were described anti-depressant medication.
29. When Baby F was aged 3 weeks Ms CM also contacted the Perinatal Mental Health Service herself and spoke to a duty worker. She described Baby F as “crying all the time” and expressed concerns about her own mental health. The allocated worker returned her call and agreed to make a home visit. A week later the visit took place as planned, but Ms CM was not at home. The worker telephoned Ms CM who said she had decided to go out.
30. A week before Baby F’s injuries, Mr CF contacted Ms CM’s GP worried about her mental health. The GP referred Ms CM back to the Perinatal Mental Health Service and was so concerned that he followed the referral up with a phone call to ensure it had been received. The authors were unable to establish whether the GP considered sharing his concerns with other agencies.
31. When Baby F was 10 days old Ms CM spoke to the GP on the phone as she was worried about Baby F vomiting and suspected he had colic. The GP gave her advice but the baby was not seen.
32. The next day, on the advice of his GP, Mr CF took Baby F to the Emergency Department due to “sticky eyes”. He was treated for conjunctivitis and reviewed two days later.
33. At four weeks of age Baby F was seen in the Paediatric Assessment Unit of the local hospital with vomiting, constipation and being generally unsettled with increased crying. A diagnosis of colic was made secondary to over feeding.
34. In the week leading up to his injuries, Baby F was seen at the emergency department of another hospital where he was described by his mother as “vomiting for 24 hours.” Ms CM also made two telephone calls to her GP surgery about the same issue and Baby F was seen by a GP who gave advice to his mother about feeding.
35. This was the last practitioner contact before Baby F was admitted to hospital with severe head injuries.
Findings and Learnings
36. There are numerous published Serious Case Reviews concerning babies who have suffered abusive head trauma; in all there is a notable similarity in the learning identified.
37. In Devon over the past three years, there have been 5 cases of babies being injured which have led to a Serious Case Review or a Rapid Review. For the Safeguarding Partnership this presents a significant challenge in how to identify and disseminate learning in order to strengthen safeguarding systems.
38. From the Terms of Reference, the written information provided to the Review and the practitioner events, the learning themes in this case can be summarised as:
- The significance of prior parental history and how this is assessed
- Understanding of the heightened risk of domestic abuse during pregnancy and the consequent risk to the infant (both unborn and once delivered)
- Comprehensive and accurate information sharing within agencies and effective collaboration between agencies
The significance of parental history and how this is assessed
39. The information that Mr CF already had a child who, at 6 weeks old, had been found to have multiple fractures became known to midwifery at an early stage in Ms CM’s pregnancy.
40. Midwifery responded promptly and made a referral to Children’s Social Care. The referral led to an assessment the outcome of which was to close the case. The practitioners and managers involved in the process have reflected on the practice (and did so openly during the practitioner event) and agreed an opportunity for a more robust assessment was missed. Practitioners agreed a multi-agency strategy meeting is crucial to ensure comprehensive information sharing to inform decisions on appropriate actions.
41. At the time of the assessment Ms CM was only 10 weeks pregnant and the information received was not seen as a safeguarding matter because Mr CF said there were no concerns following the Family Court proceedings and he was having regular unsupervised contact with this child. This was accepted at face value and provided false reassurance. There were no strategy discussions or enquiries made under s47 of the Children Act. The agreement for unsupervised contact was therefore not comprehensively explored.
 Section 47 of the Children Act 1989 places a duty on local authorities to investigate and make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and, where these inquiries indicate the need, to decide what to do.
42. The assessment was carried out on the basis of one visit, and as the procedures specify that the assessment is multiagency, conversations were held with midwifery and a “health report” obtained from the GP. The Health Visitor did not attend the pre-birth planning meeting. The authors were unable to establish whether the health report included comprehensive details of parental vulnerabilities.
43. The assessment contains detailed information about Ms CM’s history, her mental health, suicide attempts and suicidal ideation as recently as three weeks before. It also mentions that the family were, at that point, staying with a relative and were waiting for housing.
44. Understandably the main focus of the assessment is on Mr CF’s history and the injuries sustained by Child OC.
45. The assessing Social Worker had checked Children’s Social Care records and read the judgement from the Finding of Fact hearing which had taken place almost ten years earlier. This reported that, at the time, “(both parents) were implicated though a full understanding of how the injury occurred was never concluded.” This meant that no other adult was implicated but the court was unable to determine which of OC’s parents caused the injuries.
46. The Social Worker did not fully grasp the meaning of the words and was reassured by the comments, which were interpreted being inconclusive as to who caused the injury and whether the parents were implicated at all. The Social Worker was also reassured by feedback from Mr CF who said he had regular unsupervised contact with Child OC and there had been no further concerns. This misunderstanding and lack of triangulation of the contact arrangements hindered the recognition of the risk posed by Mr CF.
47. Based on Ms CM’s vulnerability the assessment concluded the family would benefit from ongoing work under the Child in Need Framework (Section 17 of the Children Act 1989). However Ms CM declined the offer of any support and as Section 17 work requires the cooperation of parents, defined as their “consent”, this wasn’t seen as a viable option.
48. Although the domestic abuse incident pre-dated the assessment, the information was not known to Children’s Social Care and therefore not factored into decision making.
49. The case was closed and signed off by a manager on the understanding that housing and the Perinatal Mental Health Service remained involved.
Use of the Child Protection Procedures
- The circumstances of the injuries sustained by a previous child who had been a few weeks old at the time were misunderstood and therefore the potential risk to future children was not recognised. When there have been previous Care Proceedings, a robust assessment must be done (in accordance with the pre-birth policy) . A Strategy Discussion and Section 47 enquires would enable detailed background checks to be carried out on parents, information provided by parents to be verified, and a comprehensive assessment to be completed to include the evaluation of risk to the unborn child
- Full information from the previous court hearings should form part of the assessment. These should also be considered in the context of the vulnerabilities of Ms CM and of the relationship
- Although there was clear recognition of Ms CM’s vulnerability, this appears to have shifted the focus away from Baby F and the impact of her vulnerabilities on her ability to parent her child safely and effectively.
The importance of understanding professional language
- The language of the Court judgement was misinterpreted. The participation of a legal advisor in the Strategy Discussion in similar cases would enable timely access to the relevant documents and accurate interpretation of any legal language and the findings of the court. Practitioners need to consult with lawyers to ensure they have understood the findings in previous hearings and formally verify claims regarding contact arrangements.
- There is some confusion regarding the terminology of assessments. Some practitioners understood the pre-birth assessment to be a “two stage” process whereas this is not defined in the Child Protection Procedures used by Devon. Practitioners indicated that previous to this case, a dedicated team would carry out pre – birth assessments hence concentrating expertise in one team which would be diluted upon dismantling this approach. The geography and rural nature of Devon offers a challenge to this approach. In order to ensure ease of access for families, building expertise into locality teams would be preferable.
Pre-birth assessments and parental cooperation
- Pre-birth assessments are a vital part of safeguarding babies. In this case the assessment was completed before the early stages of pregnancy and based on one visit. Forming a comprehensive picture of prospective parents with a complex history is not possible in such a brief period. It is important that there is collaboration with all involved agencies.
- It is important that all practitioners understand the terminology of assessments and if a case is closed that the reasons are clear.
- There is a risk that workers will be over-optimistic about risk to a new baby and that an unwillingness to agree to any intervention can be misconstrued as a parental strength when parents appear confident that they do not need any help. It is important to consider all possible reasons for the lack of engagement and the implications for the unborn child.
The need for supervision
- Given the incidence of injuries to pre-mobile babies, management oversight of pre-birth assessments is particularly important. If there is a “lack of parental consent” for ongoing work this creates an opportunity to close a case, which in a climate of high demand on limited resources, might be welcomed by managers and practitioners. Further curiosity about why parents do not want a service, how this may increase risk to the (unborn) child and the development of skills in engaging families will help ensure cases are not closed inappropriately.
Understanding of the heightened risk of domestic abuse during pregnancy
50. There was one domestic abuse incident when Ms CM was ten weeks pregnant. A Police Officer attended and in line with their procedures, used the vulnerability screening tool (ViST) which rated the risk as green, the lowest level.
 Key elements of the Devon and Cornwall Police’s Single Safeguarding Policy (SSP) are the ViST (Vulnerability Screening Tool), a risk assessment tool employed by Police Officers and Staff to assess vulnerability and the Central Safeguarding Team (CST), which receives and processes the ViST to identify cases requiring further multi-agency assessment and intervention. ViST ratings are RAG rated (red, amber and green) green is the lowest risk level.
51. Ms CM herself was assessed as a “low level risk” as she had removed herself from Mr CF, was in a safe place and was planning to see a doctor for a health check. The incident was not rated as a child protection concern because the person doing the ViST did not record the unborn child in the appropriate place although reference was made to the pregnancy elsewhere in the document . This meant that the key piece of information about the pregnancy was not appended therefore this changed the outcome of the assessment of risk.
52. A few days later a Police Officer attempted to visit Ms CM to follow up the incident and carry out a DASH risk assessment. Ms CM had returned home but was not in when the officer called. The officer followed the matter up with a telephone call however Ms CM did not fully comply with the DASH assessment and made it clear she did not wish to pursue a complaint. The record does not state whether Mr CF was with Ms CM during the phone call. The outcome of the enquiry was the risk was assessed as “standard” and no further action was taken.
 DASH Risk Assessment: The introduction of the new Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model means that all police services and a large number of partner agencies across the UK use a common checklist for identifying and assessing risk.
53. It is notable that there was no recorded attempt to check Mr CF’s history which, although he wasn’t charged or convicted, would have detailed the previous injuries to Child OC and any other information held on the police computer. The ViST was not passed on to other agencies because the link to the child had not been made (see paragraph 52). Current practice is that the Police do not pass on green rated ViSTs to other agencies unless there are at least three episodes.
54. As the ViST was not shared, other professionals who knew the family were unaware of the domestic abuse incident. Also, Children’s Social Care do not routinely contact the police for information when carrying out a pre-birth assessment therefore reducing opportunities for collecting comprehensive information.
55. There appears to be a process whereby referrals into MASH may pass straight to an assessment without following the multiagency “MASH” process of gathering information from partner agencies at the point of referral. This restricts the information available to the practitioners carrying out the assessment and with the result that the practitioners have to proactively search for agency information rather than it being shared at the point of referral. It has since been confirmed that this is no longer standard practice.
56. However, had the pre-birth assessment been carried out in a comprehensive manner, the number of risk factors (see pre-birth policy8) may have impacted on Children’s Social Care’s decision making regarding the necessity of a strategy meeting under Section 47. Had this taken place, the Police would have been involved.
57. Research informs practitioners that if the Police are called to a domestic incident it is unlikely to be the first the victim has experienced. It also informs us that when a woman is pregnant, the risk of domestic abuse increases. This means that any domestic abuse incident involving a pregnant woman must be taken very seriously and the practitioners involved with the family kept fully informed of events.
 British Medical Association Board of Science Domestic Abuse 2014
58. There is no evidence recorded that Ms CM had been asked about domestic abuse at midwifery, health visiting or Emergency Department contacts.
59. If the Police had checked Mr CF’s history this may have prompted a referral to Children’s Social Care. If Children’s Social Care and Health Visiting had been aware of the domestic incident, their own agency assessments may have resulted in a more reliable assessment of risk.
- It is known that women are especially vulnerable to domestic abuse when they are pregnant; this should inform the assessment of risk to both mother and child.
- It is imperative, that as part of the risk assessment of a pregnant woman, the background of the alleged abuser is checked and, if there is evidence of previous or current behaviours that pose a risk to the unborn child, then the case should be referred to Children’s Social Care.
- If the information is shared with Children’s Social Care and Health, the practitioners working with the family will have a fuller picture and be able to evaluate risk more effectively.
- Consideration should be given to all ViSTs involving pregnant women to be graded as at least amber to ensure the heightened risk is explicit.
- As part of risk assessments, women should be seen or spoken to alone (not in the presence of the alleged perpetrator). This means they are more likely to be able to discuss any concerns they may have about their safety.
- The practitioner event highlighted that there is a DASH risk assessment which relates specifically to alleged perpetrators. Developed by Respect (a UK domestic abuse membership organisation for work with perpetrators, male victims and young people’s violence in close relationships), the tool can be used by any practitioner to inform their risk assessment.
The importance of multi–agency collaboration
60. Pathways to Harm, Pathways to Protection states that:
“The centrality of information sharing to effective safeguarding practice cannot be stressed enough. Of the 66 serious case review reports reviewed in depth, there was only one where information sharing was not mentioned. All others identified issues ranging from direct failure to identify risk or protect the child, to simply identifying information sharing as an area for improvement.”
 Pathways to harm, pathways to prevention, a triennial analysis of serious case reviews, 2011-2014 Sidebotham et al.
61. The report highlights the challenge of “knowing when to share personal information” and suggests that “the default position is not to share unless the practitioner actively decided to do so.”
62. The report goes on to say that (if information is not shared) “this means that no practitioner would have a comprehensive overview that would enable appropriate risk assessment”.
63. In this case the information which was not known to all the agencies included detail about the injuries to Child OC and the outcome of the previous Care Proceedings, Children’s Social Care’s assessment and the outcome, the diagnosis of both parents with depression, father’s anger control and the Police’s investigation of the domestic abuse incident.
64. When information was passed on, for example the referral from midwifery to Children’s Social Care and from midwifery to Health Visiting following the pre-birth planning meeting, no feedback was sought or shared. This meant that midwifery did not know or ask why Children’s Social Care had closed the case or that the plan for ”intensive health visiting” became the “universal service” after three contacts.
65. Similarly there was no attempt to gather feedback following the second midwifery referral which would have identified that Children’s Social Care had no record of receiving the referral.
66. The GP had seen both parents and was aware of their history of mental health problems and father’s disclosure of his difficulties in controlling his anger but had not passed this information on to partner agencies.
67. For the efficient flow of information the challenge lies with both individual agencies and with systems across agencies.
68. To summarise, the barriers which prevented a cumulative picture emerging of family life were:
- Significant information was not known to all agencies
- An opportunity to use the Child Protection Procedures was lost
- Systems within organisations were not conducive to information sharing (different systems in a single organisation which did not have a common interface, uploading of information without being seen by practitioners, delayed coding in General Practice)
- When information was shared, feedback was not sought or provided
69. These factors limited the opportunity to question and challenge the decisions of other agencies and if necessary use the Case Resolution policy.
 Please note that Devon’s Child Protection Procedures (accessed 2 September 2019) still refers to “Escalation Policy” throughout and not to a case resolution policy.
- Practitioners should maintain ownership of their concerns until they are certain they have been dealt with appropriately to safeguard the child
- When new information of concern is disclosed to a practitioner, this should be shared without delay
- When transferring cases between agencies, practitioners must provide a clear and comprehensive handover of information. If cases are transferred to other practitioners within the same agency, (transferring caseloads to colleagues, covering for colleagues on leave etc) a written chronology of key events and decisions will ensure nothing is lost
Prevention of Abusive Head Trauma
70. Defined as “an inflicted injury to the head and its contents” and “associated with a spectrum of serious and often permanent neurological consequences”, abusive head trauma is the leading cause of death from abuse in children under 2 years old.
71. Dr Suzanne Smith’s work on abusive head trauma refers to the normal peak of crying known as the “crying curve” and highlights the relationship between crying and abusive head trauma caused by shaking which peaks at 9-12 weeks. Her research proposes that AHT is largely preventable.
72. Reijneveld et al describe that:
“Exhausted parents and other caregivers may become frustrated and angry and “lose it” when infants in their care cry inconsolably”
73. Altman et al quotes:
“The person most likely to shake an infant is the father or a male surrogate. Shaking typically is triggered by the caregiver’s inability to stop the infant from crying.”
 Abusive head trauma: Evolution of a diagnosis BCMJ, Vol. 57, No. 8, October 2015, page(s) 331-335, Margaret Colbourne, MD, FRCPC
 Dr Suzanne Smith, Mechanisms, Triggers and the Case for Prevention, January 2017
 Reijneveld SA, van der Wal MF, Brugman E et al Infant crying and abuse. The Lancet 2004;364:1340-2.
 Parent Education by Maternity Nurses and Prevention of Abusive Head Trauma
Robin L. Altman, Jennifer Canter, Patricia A. Patrick, Nancy Daley, Neelofar K. Butt, Donald A. Brand
74. We do not know the circumstances which led to Baby F’s injuries. However, we do know that shortly after his birth Ms CM described Baby F as “screaming all the time” and that the parents sought help with apparently minor medical issues several times in the weeks leading up to the head injuries. Both parents had been diagnosed with depression and were repeatedly seeking medical reassurance. This can be an indication parents are struggling to cope.
75. Practitioners can “medicalise” crying by seeking to apportion a diagnosis such as colic or gastroesophageal reflux. Colic is poorly understood, is self-limiting and is often treated by over the counter medication. Reflux is physiological (normal) in young infants and is widely regarded to be overtreated. Parents are often comforted by a “medical” diagnosis particularly when there are measures which can be then taken in an attempt to reduce symptoms.
76. There is a risk that this medicalisation focuses attention on treatment of symptoms rather than an exploration of the impact this has on parents and may distract from supporting them to manage their infant when crying.
77. There is currently no provision in Devon for universal access to ante – natal classes. These provide an opportunity for education of parents to be in management of the crying baby and appropriate handling of the young infants.
78. Similarly, antenatal services in Devon do not routinely provide widely available materials (e.g. NSPCC) regarding the safe handling of babies particularly with respect to the avoidance of shaking. This is a missed opportunity for education particularly for vulnerable families.
79. The Local Authority, working with the Clinical Commissioning Group, intends to explore the role of Public Health nursing in addressing this gap in service.
A strategy to address the prevention of abusive head trauma requires both a public health and a multi- agency professional response. Consideration should be given to:
- The promotion of awareness among parents and professionals of the “crying curve” (also known as “purple crying”) and the impact on parents of coping with inconsolable crying
- Education of parents in the safe handling of their young infant
- Understanding more about patterns of abusive head trauma and the associated risk factors
- Reflection on the diagnosis and treatment of depression in new and prospective parents and how this can impact on parenting capacity particularly where both parents are affected
- Understanding the subtext of frequent attendances for common or “minor” symptoms in infancy can be an indication that parents are not coping (this is especially important in combination with mental health and impulse control issues in parents)
- Developing a programme of intervention which takes into consideration when and how to engage fathers and prospective fathers
- The use of materials to engage, reassure and educate parents about infant crying and strategies for coping and impulse control 
 For examples see West Hampshire CCG – ICON project, Inspire Cornwall- the concept of the DadPad and associated App, the NSPCC’s “Coping with Crying” materials.
Considerations for the Devon Children and Families Partnership
80. The Devon Children and Families Partnership should consider a strategy to promote prevention of abusive head trauma based on learning from this case (including others in Devon and nationally) and messages from research. This should include the recognition of the impact of the crying baby on parents especially in vulnerable families. Consideration should be given to the implementation of tools aimed at supporting families to manage their crying infant.
81. The Partnership may wish to seek assurances that:
- When additional vulnerabilities are known, all pre-birth assessments are thorough so decisions can be made following consideration of all available information and management oversight should be robust and consistent
- If any agency is aware of parents’ involvement with previous Care Proceedings, then due consideration is given to initiation of a Strategy Discussion and enquiries carried out under Section 47, Child Protection Procedures. This should also apply to partners/significant others who are not the biological parent
- The increased risk of domestic abuse during pregnancy is well understood by all agencies and when there is evidence of abuse, the matter is thoroughly investigated, accurately risk assessed and information shared appropriately across partner agencies.