Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership Child LR and Child LP Learning Brief This briefing has been produced for all multi agency staff working with children and their families. The briefing sets out to share important information and learning from two (one full and one partial) Serious Case Reviews (SCR) carried out in Lancashire in 2019.

Details of the SCRs Key Learning Themes Child LR SCR was published in 2019. A copy Some key areas of learning taken from the can be requested from the Safeguarding SCRs: Business Unit here. Safer sleeping arrangements: Child LP SCR was decommissioned mid-point According to Child and Maternal Health – following completion of the criminal investigation Public Health Profiles 2015/17 Lancashire resulting in no neglect charges. had a worse than average infant mortality Both reviews were in response to sudden rating. This has been the position for a unexpected infant deaths and happened within number of years despite a number of local 2 weeks of each other. There were similar campaigns and initiatives. findings in each case which included:  Both babies under 5 months co-sleeping The SCRs highlighted: with mother who had been drinking  Good practice by Midwives and alcohol. Health Visitors who inspected the  Both had a sibling under 8 years with no sleeping arrangements for baby. previous health/education concerns.  Safer sleep was discussed with  Both had contact with a half sibling over parents and information provided. 11 years from father’s previous  More work required to enable relationship. professionals to work with families to  Both families had past involvement with make an individualised assessment children's social care in a different area of sleeping arrangements to improve but no involvement at the time of death. safer sleep for infants and reduce  Parents did not disclose past history of risk. children social care concern with  Need to strengthen the message – midwife. 'never share a bed with your baby  Different relevant information was held if either you or your partner has by GP, Health Visitor and Midwife drunk alcohol or taken drugs despite all working with the same family (including medications that may at the same time. make you drowsy) this can make  Impact of a new baby on the family was you less responsive to a baby'1 not assessed despite historical concern.  Safeguarding lead/team not consulted Low level perinatal mental health issues. despite past historical serious concerns.  NICE Guidance (2014, updated 2020)  Alcohol and drugs including prescribed states that 'depression and anxiety are medication were a feature in both the most common mental health reviews. problems (around 12%) during  Domestic abuse featured in one case. pregnancy and following birth.'  Low level maternal mental health in the  Local Perinatal Mental Health Teams other. are available to support women who  Parents were arrested following meet threshold for services. However, concerns of neglect following the deaths those with low level mental health in both cases. issues need support too.  History of criminal behaviour by parents. Assessment of Domestic Abuse and risk.  There were several gaps in information Domestic Abuse featured in 1 review. This between one agency and another. was historical serious domestic abuse in

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Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership another area. Social Care was involved at the time and parents agreed to spilt. Mother The SCRs highlighted: moved to new area and father followed and  Use of nationally recognised mental moved back in. health assessment tools such as:  Patient Health Questionnaire The SCR highlighted: (PHQ)  This is a recurring issue.  Generalised Anxiety Disorder  When a child protection referral is (GAD) made about an unborn baby where  Recognising women who would benefit historical domestic abuse exists it is from continuity of care during pregnancy good to get information from previous and following birth. children's social care teams, police  Listening and talking sessions are good and health colleagues to gain the use of a professional’s time in supporting bigger picture. women and gaining trust.  Multiagency working with families  A trusting relationship is good to provide helps to reduce risk. confidence and gain consent for early help work. Top Tips for Practitioners:  Access multiagency training and Assessment of drugs and alcohol on keep up to date with local and national parenting guidance.  Both SCRs featured alcohol and drug  Don’t keep safeguarding concerns use within the family including prescribed to yourself – discuss with your line medication. manager or safeguarding lead to  Past history was not taken into agree a plan. consideration when considering the  Share information – effective impact of caring for a new baby. communication pathways between  The Pre-Birth Protocol would have been professionals working with the same a useful tool for bringing all relevant family at the same time is essential. multiagency information together.  Be professionally curious – ask  Parents expect to be asked direct questions and get personal - parents questions about their alcohol and drug expect it! use. You may need to ask the same  Smelling cannabis in the home is a good question more than once before you way of starting a conversation about get the truth. cannabis use and safety for baby and  Ask to see where baby sleeps night other children. and day – Parents expect it! Any refusal can be considered alongside any other concerns which exist.  Key message – 'Never share a bed with your baby after drugs or alcohol, including medications that may make you drowsy. Overlay in these circumstances can lead to a criminal investigation'2

Safer Sleep tools for practitioners: Resources for practitioners and parents can be found here Thank you everyone for the work you do every day to safeguard and support children.

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