The young child of a couple of drug addicts suffered a life-threatening head injury in Brighton and Hove.
The boy had been living outside the area shortly before he was hurt and had been regarded as a “child in need”. The term “child in need” meant that the boy needed help from the council.
His parents’ move to Brighton and Hove was described as “unplanned” in an official report about his case.
The report was published in summary form after the Brighton and Hove Local Safeguarding Children Board (LSCB) carried out a “local learning review”.
The LSCB said after the review: “Child G is a young child born to substance misusing parents, who had been on a child in need (CIN) plan in another area, when he moved, unplanned into Brighton and Hove.
“Shortly after his move G sustained a life-threatening head injury.
“A multi-agency learning review was commissioned by Brighton and Hove LSCB … and it identified a number of findings which can be used to improve how we safeguard children locally.
“This includes use of the pan-Sussex unexpected child death protocol, questions on making referrals to social care out of hours, accessibility of historical information and communication with tertiary health providers.
“It is important if Brighton and Hove is to become a safer place for children to live for everyone to embrace the learning from the review and take the necessary steps to help put right the issues identified.”
The six findings were
- It is crucial to have access to all historical information regarding family history so as a thorough risk assessment can be completed. Information regarding the previous removal of children and assessments of mother were not shared because this information was not readily accessible.
- Updated assessments should always be carried out when a child subject to a child in need (CIN) plan moves into the area.
- The issue of temporary residents and the lack of referral onto the health visiting service was identified. There is a “flagging system” within practices that can highlight the child as being vulnerable on the GP system. The flagging system is not used if the family are temporary residents. G was not a permanent resident therefore he was not flagged and referred directly to the health visiting service. It is estimated that 5 per cent of patients registered at Brighton and Hove GP practices are classed as temporary.
- Frontline staff need to have the confidence to identify when a case should be referred to children’s social work and know how to do so, both during and out of normal office hours. Some safeguarding agencies were unsure of how the out of hours service operates. Health staff did not have the confidence to make a decision of risk because the diagnosis was uncertain. During office hours staff have access to named professionals for support and consultation.
- The link between life-threatening issues and the need to use the pan-Sussex unexpected child death protocol. If Child G had not survived in A&E then it is highly probably that the unexplained child death protocol would have been engaged. However, should Child G have died after being transferred to a tertiary care centre then it is questionable whether this would have been followed and as such other child protection agencies would not have been able to respond in a timely manner.
- The need for good links between primary and specialist hospitals. When children are transferred to a tertiary care centre with a serious head injury, responsibility for clinical management and safeguarding decisions move with the patient to the specialist unit. This results in local paediatricians generally not being consulted about these decisions. There is a danger therefore that if a tertiary centre does not access wider information about a clinical story, family or a child’s history, the interpretation of the injury and medical findings are potentially based on incomplete information.
“What next? The full report was presented to the LSCB at an extraordinary meeting in July 2014.
“A multi-agency action plan was produced from these findings and progress on this is monitored by the LSCB’s Serious Case Review Sub-Committee.”
