Learning and Improvement No. 1 – EN12

1. Prepared by: Hannah Hogg NSCB Development Manager July 2014 Learning and Improvement No. 1 – EN12

2. Background • EN was born prematurely and was cared for in hospital for the first three months of his life. Within six weeks of his discharge from hospital, he was found to have sustained serious non-accidental injuries. Father pleaded guilty to charges of grievous bodily harm and child cruelty and was sentenced to 3 years 3 months in prison.

3. Key Learning • Significance of bruising to non mobile babies • Potential challenges of caring for a premature baby and importance of appropriate planning prior to discharge from hospital • The importance of seeing mothers alone and raising the issue of domestic abuse during pregnancy • The importance of timely and accurate record keeping • The importance of accessing and giving proper weight to historical records • The importance of good quality supervision • The importance of ensuring the quality of agency staff

4. Actions Taken - Bruising • A Bruising Pathway has been developed to assist professionals in making appropriate referrals • It is available on the NSCB website and within the Safeguarding Children Procedures • Since the implementation of the pathway, processes around referrals for bruising to non-mobile babies have been seen to be more effective

5. Actions taken – Discharge Planning • Every premature baby will be subject of a pre-discharge planning meeting prior to leaving hospital • The meeting considers the support needs of the family as well as the ongoing health needs of the baby • If appropriate, a CAF is completed whilst the baby is in hospital and the assessment used to inform support service provision for the family

6. Actions taken- Domestic Abuse • The importance of seeing mothers alone and raising the issue of domestic abuse during pregnancy has been progressed • Midwives now routinely record whether a mother has been seen alone and asked about the issue of domestic abuse • This is also important for CSC staff where the family have a social worker and there is an opportunity to ask the question • Any information gathered should be logged and used to inform enquiries and assessments • The multi-agency practice guidance relating to domestic abuse is being revised, due for completion in November 2014

7. Other Actions Taken • The importance of timely and accurate record keeping continues to be highlighted across all agencies • The importance of accessing and giving proper weight to historical records, particularly around historical injuries has been highlighted within CSC • The importance of good quality reflective supervision has been addressed with all agencies across the NSCB partnership • The importance of ensuring the quality of agency staff has been addressed by CSC: the number of agencies used has been reduced and agency staff now stay in post for longer periods to reduce the need forchanges in social worker

8. Impact Evaluation • The Board monitors the action plans of all agencies after a serious case review has concluded • The Board also evaluates the impact of each review – the NSCB considered the impact evaluation for EN12 in March 2014 • Procedures were developed in light of the review and are now fully embedded, for example the pre-discharge planning meetings • It is further noted that the introduction of the MASH has led to better multi-agency responses to notifications concerning domestic abuse

9. Next Steps • Multi-agency practice guidance around domestic abuse to be reviewed and published in November 2014 • The NSCB multi-agency subgroup is to conduct a multi-agency audit around responses to domestic abuse and report its findings to the Board in March 2015

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