Donna Potts (Skillzone manager) and Emma Johnson (Early Help Coordinator) met to discuss how parents receive information to help them regarding caring and bringing up their children. They looked into the level of information parents receive from birth through to secondary school.

As a parent Emma felt that she was in a fortunate position working in the Council, as she has access to training on different services, information on resources and regular meetings with partner agencies regarding early identification on a range of vulnerability factors. A part of Donna’s role as SkillZone manager she attends various working groups, in order to look into the reasons for preventing accidents within the family home and how we can engage our most vulnerable parents.

Donna and Emma discussed ways in which parents receive information, through the internet, through health professionals and through other parents/friends. They talked about parenthood (especially for first time expectant parents) and that it is an exciting time however no one tells you how stressful it also can be and what you can do as coping mechanisms when it is tough. Donna talked about a workshop she attended where they showed a video ‘Shaking your baby is just not the deal’. The video is on the Wales safeguarding website to highlight to parents ways to soothe your baby and the dangers of becoming too stressed. A working group was set up to think about how we can work with all parents, with our more vulnerable parents in mind. The working group included  key agencies inc Gloucester Royal neonatal, midwifery, health visiting teams amongst various community/ statutory organisations and Celia Balbearnie (Families First Manager) who was involved in the Ben (Serious Case Review June 2016)

Ben’s Serious Case Review was commissioned due to the nature of the child’s death. When Ben was 9 months old he was brought to hospital by ambulance having collapsed whilst in the sole care of his father, Jack. At hospital he was found to be very unwell. His parents reported that he had been unsettled for the last two weeks, with increased crying and poor sleeping patterns. This had coincided, in part, with his Mother, Antonia’s return to work three weeks earlier. Jack said that over the previous two days Ben had been crying constantly and had seemed unwell. Ben died two days later of brain damage and the cause was assessed to be a non-accidental head injury.

There is now robust evidence base linking adverse childhood experiences (ACES) to severe negative health and social outcomes across the life course, including the leading causes of illness and death in the UK. Adverse Childhood Experiences (ACEs) are traumatic events occurring before the age of 18. There are ten ACEs, five which directly link to the child: Physical, Sexual, Emotional abuse, Physical neglect & Emotional Neglect. Five that link with the parents/household: Mother treated violently/ household substance misuse, household mental illness, parental separation or divorce & incarcerated household member.

Antonia ACES Highlighted yellow

Antonia had a difficult childhood, and was emotionally abused by her stepfather. She had problems with alcohol in her early teens, left home at 15 and was pregnant with her first child, Daisy at 16. Antonia continued to misuse alcohol/drugs and there were significant concerns from Swindon Children’s Services about Antonia’sneglect of Daisy, despite considerable support. This led to Daisy going to live permanently with her Maternal Great Grandmother, Sally. Antonia met Jack when she was 19. She was homeless at the time and a month later she was pregnant with Ben. She sought maternity care immediately and she reported to professionals that she was happy to be pregnant and wanted to make a fresh start. Little was understood by professionals about Jack and his family. Ben was born prematurely at Gloucester Hospital (at 30 weeks gestation) and he was initially very unwell and was moved to Bristol Hospital; he made good developmental progress and moved to Great Western Hospital Swindon. Staff at this Neonatal Unit became aware that there had been historic safeguarding concerns; there were some issues regarding late visiting by the parents on the ward and the Neonatal Unit Consultant Paediatrician made a referral to Gloucestershire Children’s Social Care (GCSC). A brief assessment was completed and no ongoing concerns were raised. Ben was discharged home after 6 weeks of being in hospital (three different hospitals). Early support was provided and the parents were visited regularly at home and they were observed to be loving and caring parents.

There should have been a pre-birth assessment at this stage to consider the balance across the strengths, of which there were a number, with the risks, of which there were more – either undertaken under the auspices of an early help response

The need to focus on Fathers in the antenatal period: There was little focus at this time on Jack, and information about his personal circumstances or his family was not sought. Therefore the midwives did not know that Jack’s own father had had a heart attack at the same time that Antonia had discovered she was pregnant, and as a result of taking time off to support his father, Jack had lost his job. An additional potential stress factor for Jack was that there was a family history of heart failure. The impact of these stress factors was not known. Jack had never been a parent and had not had the opportunity to attend parent education classes.

The Serious case review helped us to understand where we, as an Early help Partnership, failed the family and where our learning had to grow and intensify. The working group started to bring in other agencies that focussed on Vulnerable groups in the early stages of pregnancy to trail out different ways to work with our families to ensure we engage them and help them at earliest opportune moment. Celia attended a seminar by Dr Suzanne Smith regarding abusive head trauma: mechanisms triggers and the case for prevention. She mentioned that Dr Suzanne Smith had a vision to ensure all County councils embed this prevention program into their way of working. We spoke to Dr Suzanne Smith through Skype and began discussion on the way forward. Hampshire were already a few steps ahead in terms of developing their answer but were happy to guide and see Gloucestershire through as a Pilot to the prevention of future babies dying in the county and hopefully the program would then roll out Nationwide.