1. Prepared by Bob Ross NSCB Development Manager November 2015 Learning and Improvement SCR JN15

2. 5 month old child Lived with Mother, Father and Sibling Died while in the care of his mother who had a previously unrecognised perinatal psychosis Both parents are health care professionals Previously receiving universal services Background

3. Key Themes Identified Professional status and the families class and culture Parental anxiety Domestic abuse Maternal mental health

4. Good Practice Identified Good universal health service from all involved. Sibling received a timely and appropriate service in regards to his weight loss and fracture. Additional support was offered when issues were identified. Despite Mother calling the police to say she no longer required them to visit in April 2013, an officer went to the home, spoke to Mother and completed a risk assessment. Appropriate information sharing between the hospital and community health colleagues. All of the relevant professionals asked Mum how she was after the birth of JN15. She replied that she was well and this was clearly recorded in agency records. The health visitor clearly knew the family well and provided a sensitive and appropriate service to them. Record keeping was good across agencies.

5. Conclusion Lessons are limited as no professional working with the family was aware of a deterioration in Mothers mental health. The Mother was not ‘at risk’ of this condition. Mother’s (with hindsight) postnatal depression was not identified on completion of standard assessments. The family appeared to be coping well and were receiving a good universal service. However lessons about the sharing of information about domestic abuse have been identified.

6. Lessons Learned It is not current policy to share police notifications with a standard risk with health visitors, school nurses or GPs of police. The receipt of a police domestic abuse notification could increase the input to a family from universal to targeted. When pregnant a woman is more at risk of domestic abuse. Any risk assessment should take this into consideration.

7. Next Steps NSCB is to review information sharing arrangements regarding to domestic abuse notifications which are assessed as “standard risk” and particularly in relation to pregnant women.

8. Questions How does this learning impact on our area of work? Are there any issues we need to consider in relation to our practice?