Six-step Briefing: CN18 Baby F

1. The Background

Baby F was admitted to hospital at 12 weeks of age suffering from seizures. Investigations revealed severe life-changing brain injuries, indicative of abusive head trauma. This is subject to an ongoing criminal investigation.

There are numerous Serious Case Reviews concerning babies who have suffered abusive head trauma; the learning identified in each case is notably similar.

2. Safeguarding Concerns

• Poor maternal mental health was identified prior to birth, but analysis of the implications to mother’s ability to parent was not considered
• Father known to Children’s Social Care – older child with different partner injured as a baby; the Finding of Fact hearing concluded one of the parents was responsible
• Housing – the family had no permanent home
• Domestic abuse was known to be a risk factor in this family
• Lack of parental co-operation with agencies

3. The Review addressed the following issues

• How is prior knowledge of family members held by agencies and used in decision making?
• Understanding of pregnancy as increased risk for domestic abuse
• Barriers to establishing risk to unborn child
• Barriers to challenging professionals about decision making
• Barriers to effective information sharing

4. The Findings

• Pre-birth analysis of parental history is essential to inform an assessment
• Strategy discussion /S47 enquiry enables detailed background checks to be carried out and information verified, in order to evaluate risk to unborn child. Consultation with lawyers should be considered to clarify legal terminology
• Information sharing and multiagency collaboration – opportunities to use child protection procedures were lost
• Parental co-operation is key. Lack of parental co-operation or disguised compliance should be considered a risk factor when concerns are identified.
• Practitioners must consider all reasons for lack of engagement and implications for the unborn child, particularly if parents are un-willing or unable to accept help and support
• Heightened risk of domestic abuse during pregnancy – assessments did not take this into account
• Prevention of Abusive Head Trauma – there appears to be a lack of opportunity to educate new parents which may be due to changes in universal service provision

5. The Considerations

There have been 5 cases of babies being injured in Devon which have led to Child Safeguarding Practice Reviews.

• Devon SCP should review the practice of agencies working with families of babies in order to help them to understand their role in providing education on safe handling of babies and inconsolable crying
• Devon SCP need to consider how to identify and disseminate learning so that practice will change

6. Suggestions for improvement in practice as a result of this Review

Significance of prior parental history and how this is assessed

Robust pre-birth assessment as defined in South West Child Protection Procedures should facilitate multi-agency discussions and sharing of vital information.

Knowing the domestic abuse and offending history of parents is key to ensuring informed decisions are made. The grading and response to any incident should reflect this history, along with other factors.

If a parent/carer has been involved with previous Care Proceedings, due consideration should be given to initiating strategy discussion and Section 47 enquiries.

Heightened risk of domestic abuse in pregnancy and impact on unborn child

Practitioners should recognise the heightened risk of domestic abuse during pregnancy, understand the impact on the unborn child and ensure the risk grading reflects this to allow appropriate intervention.

Ante-natal assessments of pregnant women should include questions about domestic abuse and if possible, mothers spoken to alone.

If there is a disclosure or known history of domestic abuse, a risk assessment should be made to identify behaviours (past or current) that pose a risk to the unborn child and consideration given to whether the case should be referred to Children’s Social Care.

Effective information sharing and collaboration between agencies

Lack of parental consent should be analysed in terms of risk to the unborn baby or child and trigger professional curiosity.

If a pre-birth assessment is indicated it should be multi-agency. Practitioners should maintain ownership of concerns until they are certain that they have been dealt with appropriately and must use the case resolution protocol.

New information disclosed to any practitioner should be shared without delay to those other practitioners working with the family.

When cases are transferred between agencies, there must be a clear, comprehensive handover of information and a written chronology of key events and decisions to ensure information not lost.

Further Information and Useful Links

Devon SCP’s Pre-Birth (Safeguarding Unborn Babies) Procedure and Policies can be found here. And you can find more information about Devon SCP’s procedures here.

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