This is an example of where lack of information sharing has lead to a serious incident within the community.
Background
Eight weeks before death, Child M, was seen at a local A and E with cut on face. This required an overnight stay, referral to specialist surgeon and stitches. This was viewed as accidental so no follow up action took place
Child M’s mother had been known to children’s services when growing up and had suffered a troubled childhood. A past relationship with a former partner had also been an abusive one. Child M’s mother’s new partner was also known to adult services. It was known that the new partner had been abused as a child and had carried this abuse on with previous partners.
About three to four months before the hospital visit, Child M’s mother visited her GP 5x during a month but the GP treated each visit as an individual case and made no link. This was unusual as there had previously been little contact
The situation became more problematical after the hospital visit as Child M’s mother and the new partners left the area and social services found it difficult to make contact. Child M’s mother did not respond to messages and was not at home for planned visits.
There were also two other SCARFs created involving Ms M. Firstly when her former partner threatened her new partner and secondly when an ambulance was called to a domestic incident between Ms M and her new partner.
Review findings
The local authority did not have access to Ms M’s history. Although 18 months earlier LA recording became electronic – the information which would have indicated Ms M’s vulnerability had not been transferred to the electronic file.
Police, in making background checks on the adult, missed the opportunity to identify the second partner as a member of the household. Had this been done, the details would have been included on the SCARF and background checks would have alerted both the health visitor and Children’s Social Care to his presence.
Lack of appropriate sharing of the information within the professional network over time was an issue in terms of failing to lead to a more accurate assessment of the risk.
How might the DCR make a difference..
When a child is discharged from the paediatric ward, a discharge summary should be sent to the GP who should be able to review the incident in a wider context. Having information in a fully fledged DCR would enable sharing with health visitors and children’s social care if they make an inquiry about the child. In this case, information was logged at the GP’s surgery “weeks after the discharge” but at the time, there was no system in place to determine who had seen it or for the information to be shared in a consistent way with health visitors.
The hospital reported that, having reviewed the case, they would have expected to see that a telephone call had been made to the health visitor team to inform them of the injury and treatment. This call was never made which meant that the health visiting team were unaware of the incident. By putting this straight on to the DCR, this would have made a difference.
There were also issues at the GP practice regarding communication of discharge summaries due to the quasi part-paper-based system that had been in use. Changes have been made and GP’s now receive this information electronically. By having this in real time electronically, the DCR would have by-passed this issue.
Having all the information would have led to more contact/support/intervention for the child from Children’s Services