Serious case review highlights risks of concealed pregnancy

Multi agency failing in understanding risks and poor assessment highlighted in review of 18-day old baby’s death

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A serious case review into the death of an 18-day-old baby has highlighted a lack of social workers’ understanding of the risks of concealed pregnancies.

The review into how agencies in Portsmouth worked with the family prior to the child’s death found that the mother stopped attending meetings and interacting with agencies for approximately eight months before giving birth to a child, known as Child E, who she would then kill 18 days later.

The mother was later found guilty of murder and grievous bodily harm, while the father was charged, tried and acquitted of causing or allowing the death of a child.

During the period that she was out of touch with agencies, the mother received no antenatal care and stopped taking prescribed medications for depression and hypertension.

Full context not conveyed

At the hospital, after the child was born, there was an incident between the mother and father where the mother presented to midwives with blood around her mouth.

They made a referral to children’s social care, but it was decided the case did not meet the threshold for an assessment under the Children Act. and instead it was decided that the community midwife should complete a common assessment framework (CAF).

“It appears that the full context of the situation and its severity was not conveyed in the details to [children’s social care] with the outcome that the decision stood for the midwife to conduct a CAF,” the report said.

It said this decision was made with the “erroneous” information that the family were not known to services, when in fact a social work assessment had been carried out regarding them and their older child, Child F before.

“In analysing the above event it would seem that the information exchange between [children’s social care] and hospital staff was not tight or timely and there was an initial lack of understanding between the two agencies about the level of concern.

“The lack of clear procedures in respect of concealed pregnancies was also a factor in the misunderstanding between the agencies and the situation could not be moved forward by clear multi agency policy to guide practitioners, as the current guidance is not explicit.”

Shared understanding required

The review concluded agencies need a shared understanding of the risks associated with concealed pregnancy.

“Hospital staff did have an understanding of these risks but failed to adequately convey them to [children’s social care staff] staff in the first instance leading to a delay in the assessment of the family. The review has highlighted the importance of agencies making detailed and thorough referrals. The circumstances surrounding any concealed pregnancy should be subject to detailed multi agency investigation and where appropriate, support in terms of psychological or psychiatric input should be considered as part of any assessment.”

Since the child’s death, the council has updated processes around concealed pregnancy.

There is now a mandatory reporting protocol to children’s services for assessment if concealed pregnancy is suspected, and training for staff about the risks associated with concealed pregnancies is now integrated into courses offered by the local safeguarding children’s board.

‘Poor quality assessment’

The family had undergone an assessment a year previously following domestic abuse incidents and concerns about the toxic trio. The assessment resulted in ‘no further action’, and was “poor in quality,” the review said.

“It lacked analysis and relied heavily on the parents’ self-reports of the incidents without considering the experience of the child.

“There was little cross referencing with other agencies and no formal handover or step-down plan arranged.”

The review noted that since the assessment was completed practice expectations had changed and there “should now always be a clear step-down process”.

“This is important to note as there was an opportunity here to provide more coordinated, targeted support to assist the family at this time via a CAF as there were by now several indications that [the child’s older sibling] Child F’s needs were not being consistently met.”

It said agencies did not do enough to see how issues affecting the parents, such as domestic abuse, alcohol misuse and mental health, may have impacted on the family.

‘Incredibly tragic’

It was recommended that the local safeguarding children board reviews the effectiveness of early intervention services, audits the quality of referrals it receives and reviews multi-agency guidance on assessing the impact of domestic abuse, alcohol misuse and mental health difficulties.

Alison Jeffery, director of children’s services in Portsmouth, said it had been an “incredibly tragic case for everyone involved”.

“We have used the serious case review to take a critical look at how we work. We welcome the report’s findings into establishing a robust protocol for concealed pregnancies and this protocol is now in place. There are many ways parents can get help if they’re finding it difficult to cope, they won’t be judged, but they will be supported.”

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One Response to Serious case review highlights risks of concealed pregnancy

  1. Hilary Searing March 9, 2018 at 4:54 pm #

    It is hard to understand why the threshold for a child protection plan was never met as there were clearly a number of risk factors in this case. Referrals needed a timely child protection response and good information-sharing between agencies. A child protection plan would have focused more on the evidence of unsatisfactory parenting and the possible risks to children.