Presentation to Swindon Safeguarding Children Board Conference 12 October 2016 Helen Davies

2 Serious Case Reviews Child D aged 2 weeks March 2013 – March 2015 Child S aged 8 weeks April – October 2015 Focus on learning for organisations – systems Not yet published

Common themes Co sleeping on sofa Well known to agencies – child protection plans/interim supervision order Neglect Maternal ill health Mothers’ traumatic childhoods/older children in care

Positives Prompt visits to mothers and babies after hospital discharge Safe sleeping addressed In 2015: Multi agency working Strong commitment Focus on children/ siblings – advocates Identification of neglect Effective safeguarding procedures – core groups Care proceedings

Learning Gaps in communication GPs and social workers Between hospitals Between hospital and health visitor/midwife Between hospital and social worker Hospital checks re CP plan Hospital not thinking child Failure to convene discharge planning meetings

Learning Gaps in assessment Lack of chronology on social work file Mother’s mental health diagnosis Mother’s alcohol and drug use Nature of mother’s seizures Identity of male partners and their parenting capacity Father’s role in family Viability of grandmother Measuring change and outcomes (health visiting) All relevant information in hospital records not known to midwives

Identification of capacity to change Learning (cont) Identification of capacity to change Impact of mother’s childhood on parenting Impact of her lifestyle Apparent changes taken at face value False optimism

Mothers/impact on staff Learning (cont) Mothers/impact on staff Needy care leaver Distracted by her own needs Disguised compliance Impact of traumatic pregnancy and major surgery/effects of strong painkillers Impact of period in ICU on health and functioning

Learning (cont) CP Processes Few core group meetings Implementation of CP plan not addressed at reviews Paediatrician not at strategy meeting No pre birth conference

Learning (cont) Escalation No escalation by Conference chairs Health visitor Community midwife

Learning (cont) Legal processes Ample evidence to use it (D) Delays in convening meeting before action (7 months) Delays in completing required assessments Removal in context of neglect

Organisational issues Learning (cont) Organisational issues Changes of social workers and managers Health visitor workload/supervision Workload of safeguarding midwife Delay in community paediatric assessment Cover for vulnerable baby when health visitor not available Hospital IT systems

Questions What changes are necessary in light of these findings? What recommendations would you make to the Safeguarding Children Board? What might be the barriers to making the changes?