Suzanne Watts
PhD Student, Doctoral Training Programme for Children and
Young People
Oxford Brookes University
Department of Psychology, Social Work and Public Health
Suzanne.watts-2011@brookes.ac.uk
Mobile: 07956 396 009
I am always interested to hear how Trusts may respond to the recommendations and questions raised from this SCR. Please get in touch with me if you want to discuss anything raised in this overview or give me some feedback.

Overview of recent Serious Case Review of the circumstances concerning child I – Kieran Lloyd
(Northamptonshire SCB) with reference to lessons for health visiting practice teachers and universal services.

Overview Report into a Serious Case Review of the circumstances concerning Child I – Kieran Lloyd
Independent author Dr John Fox, November 2012
Northamptonshire SCB
Published on website 19 February 2014 http://www.lscbnorthamptonshire.org.uk/pro_scr.html
or via NSPCC website http://www.nspcc.org.uk/Inform/resourcesforprofessionals/s erious_case_reviews_homepage_wda82779.html

Mother - Kelly Quinn (aged 19 years at time of birth)
Father -Ben Lloyd (aged 23 years at time of birth)
Kieran Lloyd born late January 2012 died aged 8 weeks

• 16/6/2011 Routine booking appt with community midwife at GP surgery. Not asked about domestic abuse as friend present. Disclosed she smoked and had previously engaged in binge drinking. Ben
Lloyd was father. Staying with friend as mother did not know about pregnancy.
• 2/8/2011 failed to attend hospital appt with
Consultant Obs. GP informed but did not inform midwife.
• 29/9/2011 Routine antenatal visit at GP surgery
• 18/10/2011 Antenatal appt with midwife ‘no concerns about her wellbeing’
• Late January 2012 Kieran Lloyd born at
Northampton General Hospital. Ben Lloyd present with Kelly’s grandmother.
Evidenced
NGH medical records

11/11/2011 Kelly makes homeless housing application. 15/12/2011 application for housing benefit. Dec 2011 Ben and
Kelly move into one bed flat.
Sole occupants
16/6/2011
Booking
2/8/2011
Failed appt
29/9/2011
Routine appt
‘Kelly was around 6 or 7 months pregnant at the time, and when I got there Kelly was in her pyjamas, I noticed that she had a bruise and possible a cut above her left eye. She told me that there had been a row between Ben and Kelly and Ben had hit her’
Revealed during police interview for homicide
18/10/2011
Routine appt
Jan 2012
Kieran born

• Birth: Weight 10 th to 50 th centile. Kieran no abnormalities, APGAR good. Kelly discharged herself against medical advice. Self discharge form not correctly completed. GP not informed.
• Day 1: Postnatal visit by midwife. Ben Lloyd present. ‘non eventful. Flat was clean and tidy and baby was clean and well fed, good contact between mother and baby during feeding. ‘no concerns’
• End of January 2012 case transferred to HV.
Handover did did not take place correctly. Family allocated to a student health visitor
Evidenced
NGH medical records

• 1 Feb 2012 Student HV saw Kieran at home. Baby examined and no abnormalities noted.
• No recorded evidence of post visit supervision discussion with mentor, although student reported it occurred..
•
8 Feb 2012 2 nd visit by student HV at home. Kelly and Ben present. Nothing untoward noted.
• No evidence of post visit supervision discussion with mentor, although student reported it occurred.
•
7 March 2012 Student HV saw Kieran at home for 6 week check. ‘six week review sheet shows physical examination completed as satisfactory. Reaching expected milestones.
No parental concerns. No signs of postnatal depression noted’.
• No recorded evidence of post visit supervision discussion with mentor, although student reported it occurred.
• 8 March 2012 GP undertook 6 week check. GP 100% sure no bruises on body at check
• 17 th March 2012 Kieran taken to A&E failed to respond to resuscitation. Age 8 weeks. Injuries included rib fractures, bruises on limbs and abdo; fatal head injury
NHFT (Health overview report)
NHFT (Health overview report)
NHFT (Health overview report)
NGH medical records

3 Feb Police IMR
Ben’s brother release from prison on 21
Feb, to live with Ben and Kelly
12 Mar Police IMR
Ben arrested for burglary.
Kieran in pram ‘ only took a quick glimpse of baby as she moved around the pram . No concerns about welfare of child property clean and safe
1 Feb
StHV visit
8 Feb
StHV visit
29 Feb Police IMR ‘ there is a lot of noise coming from the flat of Ben Lloyd and Kelly Quinn late evening and into early hours of the morning’
Kieran 6 weeks old
7 March
StHV visit
17 March
Kieran RIP
12 Mar Police IMR
Ben’s brother had now left following dispute with
Kelly. Earlier reports by neighbors of brother with cocaine and smell of cannabis from home.

 What relevant historical information prior to Kieran’s birth was known to the agencies about the background and experiences of Kieran’s parents?
 Were there any signs or indicators that Kieran may be at risk and that his parents might not be able to protect him from these risks?

 Family GP held a body of historic evidence regarding both parents adolescents, some of which could be considered significant
 NGH held information in paediatric archive
 Maternal records are accessed by midwives on GP IT system. However, if risks and past events are not flagged up, then midwife would not be aware of them.
 The mother and unborn baby are the client of the midwife.
Midwife dependent on information from the mother

 Midwives need to be clear about their ability to access notes. The Data Protection Act is not relevant and is not a block to accessing paternal records if necessary, with or without consent
 Information not shared within single agency – Health

Ben Lloyd born 1989
•
July 1991 on CP register for emotional and physical abuse
• May 1999 Initial Assessment and police report that he had been assaulted by his mother
• 2002 CAMHS review – ADHD characteristics
• 2004 aged 15 GP notes: ‘apparently no schooling for 2 years’
• 2004 referred to CAHMS
• 2005 CAMHS feedback ‘considerable social and family disruption, the impact of which should not be underestimated’
• 2009 A&E alcohol related issues and suspected overdose
Kelly Quinn born 1992
•
2002 alleged sexual abuse by sister’s partner (disclosed to CAHMS in 2004)
• 2003 panic attacks
• 2004 referred to Paeds for counseling following nieces limb amputations
• 2006 mother requesting tablets to
‘calm her down’ thought PTSD. Older brother in prison for drugs. History of aggression at school. GP commented on sexual abuse
• O ct 2006 excluded from school for being non compliant. Referred again to Psychology
•
2006 reported to be back at school
• 2007 discharged fro CAHMS having made good progress
Even if risks known, unlikely to change actions of midwife due to period of time, however different questions could have been asked

 Was the required knowledge, skills and experience regarding the identification of and response to child abuse available within agencies?
 Were there any gaps that may have impacted upon the outcomes for Kieran?

 StHV allocated. Difficult to assess if a qualified HV would have managed the case differently….perhaps a StHV might be less well equipped to subtly gather information about the parents by asking gentle pertinent questions.
 StHV identified issues in a systematic way
 Possible injuries occurred after the last HV contact.. there is no reason why the StHV would have detected child abuse
 Relevant information was available but not accessed , suggesting a
risky family, examination required as to whether enough consideration was given when allocating such a family to a student

 Qualified as nurse 2003
 August 2011 commenced HV training
 Sept 2011 with mentor in practice
 Nov 2011 carrying out independent visits
 View of panel that she was a very capable but let down by supervision

 Made by Practice Teacher or HV mentor
 Decision to visit independently did not appear to have been reached in an informed and professional way
 No evidence of formal competency framework or assessment tool to reach this decision
 StHV had not had any advanced safeguarding training
 Root of the problem traced back to general failure by health professionals to access all available information. Exacerbated by no formal handover from midwives to health visitors
 NB PT holding a caseload of 700 children above national average of
400 cases

 Failure to adhere to trust policy: ‘it is the responsibility of supervisors to keep clear and accurate and up to date records’
 HV service did not ensure that a practitioner with the required knowledge, skills and experience regarding the identification of and response to child abuse was allocated to Kieran and his family
 ..
her supervision may have been less then adequate at least in the sense of recording the supervision sessions

 With hindsight could anything be done differently?
 Would these actions have had an impact on the outcomes for the child?
 Should a referral have been made?
No known event or acquisition of information which would have reasonably led to a referral to children social care

 Two key times when actions and assessments and decisions of midwife or GP may have had a bearing:
1. At confirmation of pregnancy
2. At the 6 week check
 Midwife did not ask about domestic abuse. Missed opportunity on three occasions.
 StHV asked about domestic abuse at primary birth visit and no concerns were identified.
 Kelly claimed she showed abdo bruises to GP at 6 week check and told ‘abnormal blood vessels’. In light of forensic examination ‘bruises on Kieran’s abdomen were not present at the time of the 6 week check’

 Historical information was not accessed as there were no obvious safeguarding concerns.
 Only by reading the historical notes would issues have been identified.
 This was not a run of the mill family (sect 5.5.5). Kelly was young first time mother in a new relationship with the father of whom little is known
 ‘It seems entirely reasonable to suggest that in such a case a more detailed examination of medical notes should be routinely carried out
(sect 5.5.5)

 If information accessed, about parents backgrounds, this should have triggered a more intensive assessment of parenting and possibly enquiries under the CAF (sect
7.0.2)
 However, GP records not accessed as there were no safeguarding concerns
 Each parent with ongoing primary care giver responsibility should be considered as a ‘client’ of the relevant health professionals
 NOTE Rec 4 regarding access to paternal medical records ‘ after a review the legal position is undertaken

 Work of StHV was satisfactory.
 Concerns about the process as to how she was allocated to this family
 Concerns of lack of adequate supervision
 If information had been accessed, there was sufficient evidence to suggest tat this was not a suitable family to be allocated to a StHV
 The SCR did not identify serious failings by agencies or professionals which might clearly have a bearing on the outcome .

LSCBN should be concerned about a perception by NGH staff that they cannot access relevant notes of the father of a child due to data protection laws. It is recommended that after a review of the legal position is undertaken, the LSCB
Chair writes to the Chief Executive of the Trust to seek reassurance that the fathers in potentially vulnerable families will be subject to the same level of enquiry as mothers .

The LSCB Chair should write to the Department of Health inviting them to note the perception revealed by this
Serious Case Review that information about fathers cannot routinely be accessed or shared between health professionals, and that Midwives only consider the mother of a child to be their ‘client’. The Department of Health should be asked to explore whether its own guidance contributes to this perception or does enough to dispel it.

 Assessment of student’s competency to visit independently. How are students assessed to be competent to visit independently?
 Suitability of families for independent visiting . Is this a risk assessment? If so, for whom? How accurate is a risk assessment with incomplete information?
 Documenting supervision. Where, what, how and why?
 Accessing information from other health professionals records . Can you? Should you? If so, whose records and why?