7 Point Briefing: Local Multi-Agency Review - Jacob
Jacob is a 2-month-old baby boy who, at the time of the incident, was living with his parents. Prior to Jacob being born, multi-agency partners identified a number of worries for his parents that could negatively impact on their ability to safely care for Jacob, including instability of housing, drug misuse, experiences of developmental trauma and domestic abuse. Due to these worries, a pre-birth assessment was completed which led to a multi-agency Child Protection Plan for Jacob for emotional abuse.
Jacob was taken to hospital after an ambulance was called to his home address as he was described by the caller as floppy and limp. Following investigations including a computed tomography (CT) scan it was established that Jacob had bleeding to his brain, consistent with a non-accidental injury. The CT scan also indicated the possibility of an additional, less recent bleed, suggesting that Jacob may have experienced more than one non-accidental injury.
Due to the significant injuries Jacob sustained, this case was referred to the National Panel by the local authority, and the City of York's Safeguarding Children Partnership instigated the Rapid Review Process which explored the following themes identifying areas of good practice and learning:
- antenatal care and booking
- referral and assessment, Multi-Agency Safeguarding Hub (MASH) and child protection process
- birth and discharge
- paternity/alleged sexual assault
- domestic abuse, substance misuse
- housing
- mental health
- wellbeing and trauma
Areas of good practice highlighted
At the antenatal booking appointment, the midwife recognised parental vulnerabilities that gave her safeguarding concerns for unborn Jacob and made appropriate referrals to support the health and welfare of mum and unborn Jacob. Information was appropriately shared with health professionals including Primary Care and Health Visiting.
The Rapid Review identified that responses by agencies to the incident were timely and robust and demonstrated effective multi-agency safeguarding processes.
Prior to the incident, practitioners working with Jacob's parents supported them in developing their parenting skills and thinking about how to be the best parents they could be to him. Both parents talked about wanting Jacob, said that they wanted to raise him and would fight to keep him in their care.
Practitioners considered the neurodiverse needs of Jacob's mum and discussed with her appropriate adjustments that would be required for her to access information.
Work was undertaken which aimed to ensure that the burden on parents of repeating information to multiple professionals was minimised.
Extensive work was undertaken with the family with regards to Safe Sleeping advice and the ICON messages. This included sharing information with the father.
A referral from a family member detailing concerns regarding domestic abuse, was responded to appropriately by the MASH.
There was good evidence of agencies sharing information and holding appropriate meetings, agreeing as a partnership that the threshold for statutory intervention was appropriate and proportionate.
Management of domestic abuse concerns showed that practitioners understand safeguarding processes and practice and worked effectively to ensure a robust and swift response and consideration of risk of harm to children and others.
The Public Protection Notice (PPN) was received by midwifery and was shared with the community midwife. The Multi Agency Risk Assessment Conference (MARAC) research and MARAC attendance was completed as per the hospital standard operating procedure.
Jacob's parents were well supported in taking on the tenancy of their family home. Additionally, the property was decorated, carpeted and furnished as part of the local authority's leaving care offer.
Professionals identified the potential risks of drug misuse in pregnancy and the risks of this to unborn Jacob which including monitoring of the baby after birth.
Midwifery followed the hospital’s perinatal mental health pathway, which recommends use of the screening tools (GAD 7 and PHQ 9) and there is evidence of appropriate referrals made to Trust Maternity Amethyst Team and the Perinatal Mental Health Team.
A hospital passport was completed for both perinatal mental health and neurodiversity to support parents during hospital admissions and help staff understand their needs. Discussions took place with regards to the use of the advocacy service to support Jacob's mum.
Key learning points
The following multi-agency learning points were identified as part of the Rapid Review Process:
Learning point 1 - SMART protection plans
All concerns highlighted within a danger statement must be translated into Specific, Measurable, Achievable, Relevant, Time-bounded (SMART) actions within a child protection plan.
Learning point 2 - Sexual abuse medicals
Where there is an allegation of sexual abuse being perpetrated against a child or young person a sexual abuse medical should be considered and offered, regardless of gender.
Learning point 3 - Challenging unconscious bias
Within multi-agency safeguarding practice, partners are expected to make individual decisions and to challenge decisions when they do not agree with them. Every practitioner should be alert to the potential impact of unconscious bias on decision-making.
Learning point 4 - Antenatal routine enquiry
Routine enquiry is recommended to be undertaken on a minimum of 2 occasions across maternity settings during the antenatal period, which was not achieved in the case of Jacob.
Learning point 5 - Care leaver housing
Where a young person who is a care leaver has contacted the local authority to explore housing options, workers must ensure that the young person is contacted, kept up to date and given timescales to when housing is available.
Learning point 6 - Homeless pregnancy priority
Where a young person presents with homelessness and in pregnancy, partners must ensure that housing needs are considered as a priority.
Learning point 7 - Parental drug risks
Where there is evidence of parental drug misuse agencies must understand the potential risks and impact of substance misuse by parents/carers to both unborn babies and children.
Learning point 8 - Sharing drug concerns
When agencies become concerned about potential parental drug misuse, they must ensure that all agencies working with the family are aware of the concerns. Where there is evidence of substance misuse then appropriate referrals to support services are required.
Learning point 9 - Challenging parental denial
Where parents deny using substances and there is contrary evidence or information, then further work is required to explore with and challenge parents to understand the impact of this on their child.
The voice of Jacob
If Jacob were able to speak to communicate his needs and feelings, the reviewers feel that Jacob would say that, in order to feel safe and loved, he needs to live in a warm, secure and nurturing home environment with people who love and care for him and prioritise his needs consistently.
We know that during Jacob’s first 2 months of life, something, or a series of somethings, happened which caused him serious injury. Jacob is likely to have been in pain and distress, instead of experiencing being soothed and comforted. It appears that Jacob’s experience of adults (or an adult) has been inconsistent. At times he has been observed to receive sensitive and attuned care, while the medical information suggests he has also been handled in such a way as to cause him serious harm.
Next steps
A multi-agency action plan has been produced and monitored by the Case Review Subgroup.