Director of Nursing and Patient Safety. Named Nurse Safeguarding Children & Head of Safeguarding

Transcription

1 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SAFEGUARDING CHILDREN ANNUAL REPORT Report to the Trust Board 26 September 2017 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director of Nursing and Patient Safety Named Nurse Safeguarding Children & Head of Safeguarding The purpose of this report is to provide both assurance and evidence to the Somerset Partnership NHS Foundation Trust Board that the Trust is fulfilling its statutory responsibilities to safeguard children and young people against the guidance set out in Working Together to Safeguard Children, (HMGov, 2015). Key Achievements the Trust was subject to a full review of its services in March The subsequent report recorded no concerns with the quality and delivery of safeguarding services across the Trust; the Trust completed the Somerset Safeguarding Children Board Section 11 Audit and assessed themselves as Outstanding. This result was later reviewed and upheld by a multi-agency Peer Review process; the Trust has embedded an updated referral process and Threshold Guidance following launch by the Local Authority and Safeguarding Children Board in November 2016; safeguarding children training rates have averaged 92% compliance over the reporting period, a slight decrease of 2% from the last reporting period. The action plan in respect of the Care Quality Commission Review of Children Looked After and Safeguarding in Somerset, (CQC, 2015), is complete. Key Risks / Mitigating Factors increasing child protection activity, particularly within the Trust Health Visitor service whilst the service itself is decreasing by 40 whole time equivalents. o Health Visitor child protection clinical supervision delivered by dedicated Safeguarding Children Nurses with specific knowledge and expertise in child protection. o Provision of annual half day Level 3 safeguarding children training in line with the Intercollegiate Document Safeguarding children and young people: roles and competences for health care staff. o Named Nurse works closely with Public Health Nursing September 2017 Public Board - 1 -

2 Managers to review caseload weighting Named Nurse reviews DATIX reports to identify themes and trends in child protection activity and to ensure robust action plans are devised and implemented to address risk issues identified. the ongoing Baby Sam Serious Case Review has not yet been published. However the Trust has begun implementation of comprehensive action plan of improvements of key practices and processes within the Health Visitor service; the ongoing Operation Fenestra Child Sexual Exploitation Serious Case Review has not yet been published. However the Trust has begun implementation of a comprehensive action plan to address the issues identified; communication difficulties with partner agencies, namely Children s Social Care and Midwifery providers continues to be reported via DATIX o Implementation and embedding of the Safeguarding Children Board Resolving Professional Differences Policy. o Regular meetings between Public Health Nursing Managers and their Midwifery provider counterparts to manage poor communication. o A strategic multi-agency meeting is planned to review the situation and devise a new plan to address the ongoing issues. the role that Somerset Partnership plays in the Multi Agency Safeguarding Hub has increased significantly in the past year resulting in the Safeguarding Children Team being less available to Trust staff. The Safeguarding Team have implemented a duty system with a single point of access contact number The MASH workload is covered by the Locality Safeguarding Children Nurses working a weekly rotation into the MASH. Additional Key Issues and Recommendations: the Government have accepted the recommendations of the Wood Report which will lead to changes within both the Safeguarding Children Board and Child Death Review process; the Local Authority Children s Services were subject to a monitoring visit by OFSTED in November 2016 which concluded that adequate improvements were being made. A further inspection is expected in Autumn 2017; numbers of Child Protection Case Conferences convened in 2016/2017 have increased by 10% compared to the previous year, neglect and emotional abuse continue to be the largest September 2017 Public Board - 2 -

3 Actions required by the Board: categories of Child Protection Plans; during 2016/2017 there were 24 child deaths. 27 child deaths have been reviewed at the Child Death Review Overview Panel. The Trust Board is asked to accept this report as evidence that Somerset Partnership NHS Foundation Trust has in place robust arrangements to safeguard and promote the welfare of children and young people in accordance with Section 11 of the Children Act The Trust Board is asked to approve the Safeguarding Children Declaration for as detailed in Appendix 4. September 2017 Public Board - 3 -

4 September 2017 Public Board - 4 -

5 SAFEGUARDING CHILDREN AT RISK ANNUAL REPORT Named Nurse for Safeguarding Children & Head of Safeguarding July 2017 September 2017 Public Board - 5 -

6 SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SAFEGUARDING CHILDREN ANNUAL REPORT Section CONTENTS Page 1 PURPOSE 8 2 INTRODUCTION 8 3 NATIONAL STRATEGY AND GUIDANCE 9 4 SOMERSET LOCAL SAFEGUARDING CHILDREN BOARD 15 5 CHILD PROTECTION ACTIVITY 22 6 SAFEGUARDING ARRANGEMENTS WITHIN SOMERSET PARTNERSHIP 7 POLICIES AND COMMUNICATION 31 8 SAFEGUARDING CHILDREN TRAINING 33 9 APRIL 2015 REVIEW OF CHILDREN LOOKED AFTER AND SAFEGUARDING SERVICES IN SOMERSET 10 AUDIT CHILD DEATH REVIEW SERIOUS CASE REVIEWS MULTI-AGENCY / HEALTH COMMUNITY / NEAR MISS REVIEWS SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRI) UNTOWARD INCIDENTS CHILDREN LOOKED AFTER SAFER RECRUITMENT NEXT STEPS RECOMMENDATIONS 49 APPENDIX 1 Health Visitor and School Nurse Child Protection Activity 50 APPENDIX 2 CAMHS Child Protection Action Activity Data September 2017 Public Board - 6 -

7 APPENDIX 3 Health Visitor and School Nurse Workforce Planning Data 57 APPENDIX 4 Draft Safeguarding Children Declaration 2017 / September 2017 Public Board - 7 -

8 SAFEGUARDING CHILDREN ANNUAL REPORT PURPOSE 1.1 The purpose of this report is to provide both assurance and evidence to the Somerset Partnership NHS Foundation Trust Board that the Trust is fulfilling its statutory responsibilities to safeguard children and young people. 1.2 The purpose of this report is also to inform the Trust Board of child protection activity during the period 1 st April 2016 to 31 st March INTRODUCTION 2.1 Safeguarding children and protecting them from harm is everyone s responsibility. Everyone who comes into contact with children and families has a role to play. Somerset Partnership has a statutory responsibility to make arrangements to safeguard and promote the welfare of children and young people, (as set out under Section 11 of the Children Act, 2004). 2.2 Keeping children safe is a complex and demanding activity which requires practitioners to have high levels of commitment and skill. All Trust staff who come into contact with children and young people have a responsibility to safeguard and promote their welfare and should know what to do if they have concerns about safeguarding issues, including child protection. 2.3 This report provides the Trust Board with assurance that Somerset Partnership is meeting its statutory responsibilities as set out under Section 11 of the Children Act This report provides an overview of the Trust s current position and progress in ensuring robust systems are in place to safeguard children and young people. The report also provides details on planned future service developments. 2.5 Safeguarding and the protection of children continue to have a high profile nationally where continued reform requires translation and embedding in the local context. Specifically the Independent Inquiry into Child Sexual Abuse is ongoing but has had a fourth change of Chair. The resignation of Dame Lowell Goddard in August 2016 resulted in the appointment of Professor Alexis Jay. The Inquiry has statutory status and includes twelve separate investigations including those into MPs, local councils and church organisations. Whist Somerset Partnership has been notified about the scope of the review and the need to preserve clinical records, it is not yet clear whether the September 2017 Public Board - 8 -

9 Trust will be required to submit information to any element of the Inquiry. Whilst the Inquiry is not likely to conclude until 2020 it is likely that interim findings will have significant impact on both local and national safeguarding policy and processes and that there will be many lessons to be learned within the final report. 3. NATIONAL STRATEGY AND GUIDANCE There have been no major changes in national strategy or guidance during 2016/2017. The Children Act Section 11 of the Children Act places organisations under a duty to ensure that, in discharging their functions, they have regard to the need to safeguard and promote the welfare of children. This guidance sets out the key features of effective arrangements to safeguard children which all agencies need to take account of when undertaking their particular functions. 3.2 To discharge the duty under Section 11 of the Children Act the Trust is required to be compliant with the Care Quality Commission Outcome 7 and Standard 5 of the National Service Framework for Children both of which relate to safeguarding and promoting the welfare of children and young people. 3.3 The Children Act 2004 reinforces the statutory duty on the NHS to contribute to the achievement of the five outcomes identified for children and young people in the Children s Bill 2004, and to co-operate in the functioning of the Local Safeguarding Children s Board (LSCB). 3.4 Under Section 10 of the same Act, organisations including NHS Trusts are required to cooperate with local authorities to promote the wellbeing of children in each Local Authority area. This cooperation should exist and be effective at all levels of the Trust, from strategic level through to operational delivery. Therefore staff working for the Trust are responsible for ensuring that they fulfil their role and responsibilities in a manner consistent with these statutory duties. Children and Families Act The Children and Families Bill was drawn up by the Conservative/Liberal Democrat Coalition Government in 2013 to support reforms to ensure that all children and young people can succeed, no matter what their background 3.6 The resultant Children and Families Act 2014 became law on 16 th March However the majority of the family justice provisions in Act became law on 22nd April 2014, at the same time as the launch of the new single family court. September 2017 Public Board - 9 -

10 3.7 The Act seeks to improve services for vulnerable children and support strong families. The changes to the law give greater protection to vulnerable children, better support for children whose parents are separating, a new system to help children with special educational needs and disabilities, and help for parents to balance work and family life. 3.8 The Act also ensures vital changes to the adoption system can be put into practice, to ensure children are placed into permanent homes more quickly. The Act has also reformed foster processes giving Children Looked After the choice to remain in their foster families until their 21 st birthday. 3.9 In summary the Act seeks to reform legislation relating to the following areas: adoption and children in care; aspects of the family justice system; children and young people with special educational needs; the Office of the Children s Commissioner for England; statutory rights to leave and pay for parents and adopters; time off work for ante-natal care; the right to request flexible working. Care Quality Commission 3.10 The Care Quality Commission is the independent health and adult social care regulator for England, regulating care provided by the NHS, local authorities, private companies and voluntary organisations Somerset Partnership, along with its Somerset Health Community partners, (Yeovil District Hospital NHS Foundation Trust and Taunton and Somerset NHS Foundation Trust), were last subject to an unannounced Review of health services for Children Looked After and Safeguarding in Somerset by CQC between April Since that time Somerset Partnership has been subject to a full CQC inspection of its services. This took place in March 2017 and resulted in the Trust moving from Requires Improvement to Good overall with no significant safeguarding concerns being identified. Whilst safeguarding children was not the subject of this inspection and given this report has been compiled since the report was published it should be noted that the following feedback was given by CQC in respect of safeguarding: September 2017 Public Board

11 Across all services, we found safeguarding systems and processes were understood by staff and implemented to keep people safe. Safeguarding concerns were recognised and reported promptly to ensure patients were protected. Safeguarding training at enhanced level three training appeared low in community health inpatients. However, this was due to the trust reviewing which staff required this proactively in line with draft national guidelines from NHS England. This meant more staff were required to attend the training than previously which had affected the training figures. There was a detailed training plan to meet the new standards. Prior to the new standards being adopted by the trust the compliance rate for level three was 97%. CQC Inspection Report, June 2017 Office for Standards in Education, Children's Services and Skills, (OFSTED) 3.12 Somerset County Council services for children in need of help and protection, children looked after and care leavers were inspected in 2015 and found to be inadequate. A Multi-Agency Improvement Board was implemented monitoring a comprehensive Improvement Plan which has since evolved into the Somerset Children and Young People s Plan which is now monitored by the Somerset Children s Trust Board. Subsequently OFSTED completed a monitoring visit to assess progress made following the inadequate judgement. This took place in November 2016 and concluded that the County Council were making adequate progress in improving services for children and young people in need of help and protection in Somerset. As Somerset Partnership is a key improvement partner in this process they are represented at all levels of the governance structure responsible for implementing the Plan. Key elements of the 7 improvement programmes for 2017/2018 relate to Trust services: 1. Supporting children, families and communities to become more resilient o promote volunteering opportunities and peer support models such as breast feeding peer support, grow, cook, eat projects and compassionate communities that support people who are bereaved; o o make the best use of community resources e.g. using libraries, leisure centres, children s centres, GP health centres, community hospitals as health and wellbeing centres and other council buildings to promote health and wellbeing in local communities; map what s available and what s effective for children and families across Somerset, ensuring this is captured on September 2017 Public Board

12 o Somerset Choices and share good practice across area based team Promote healthy life choices through Making Every Contact Count training for all health, care and education professionals working with children and young people and their families. 2. Promoting healthy outcomes in families and giving children the best start in life o promote breastfeeding and peer support programmes in a further two areas of deprivation in ; o o o continue to improve transition planning for children and young people with long term conditions and disabilities; consultation and implementation of the new public health nursing service; recommission the health assessments service for children and young people looked after and leaving care to develop a multiagency health offer in local venues and using access to digital technology. 3. Improving emotional health and wellbeing o continue to develop the new CAMHS services and embed the new posts created in with integrated pathways to join services up; o o o o implement the perinatal mental health care pathway for vulnerable mothers experiencing mental health problems; provide support and education for parents to enable increased understanding and awareness of emotional and mental health issues along with strategies to support children and young people, including access to tools and additional support where needed; continue to support staff in education settings with a focus on prevention and vulnerable groups (including joint casework with counsellors, PFSAs, psychologists and other education support staff) through provision of emotion coaching programmes and CAMHS liaison posts for schools; ensure that training and support for professionals working across universal services is in place. September 2017 Public Board

13 4. Building skills for life o ensure all collaborations are clear about their purpose and aims, and can evidence their impact on outcomes for children and young people; o work with partners, communities and businesses to increase the support and range of opportunities for care leavers to move into further and higher education; or work based training and apprenticeship. 5. Providing help early and effectively o map partnership early help resources with an aim to shift from crisis intervention to prevention; o o consult on the new approach to provision of children s centre services encompassing the commissioning of public health nursing services within a wider partnership of health, education and community support; undertake first annual self-evaluation of the partnership s approach to early help utilising the Early Intervention Foundation matrix tool to inform future actions and ensuring continuous improvement. 6. Achieving effective multi-agency support for more vulnerable children and young people and develop an excellent children s social work service o develop proposals for integrated multi-agency specialist services hubs providing evidence-based support for the most vulnerable and challenging children and their families; o complete an assessment of future IT based. 7. Embedding a think family approach across the workforce o implement a new service delivery model to enable successful transitions based on integrated, multi-agency and multi-disciplinary ways of working; o o agree a model of integrated, multi-agency area teams providing evidence based interventions based on good practice nationally (this will encompass the early help hubs in programme 5 and specialist hubs in programme 6); consider further rollout of One Teams with potential for wider involvement of local partners and make appropriate use of learning from it across the county in targeting vulnerable families and providing community-based support; September 2017 Public Board

14 o o use the shared intelligence of partners to target resources more effectively to the needs within different localities within Somerset; promote a new professionals directory within Somerset Choices so practitioners know who else can help them in supporting their families. A further OFSTED review of the Local Authority is expected in September 2017 and will likely involve partner agencies including Somerset Partnership. Working Together to Safeguard Children 3.13 There have been no further revisions of the Working Together to Safeguard Children, (HMGov, 2015) guidance since the 2015/2016 Trust Safeguarding Children Board Report. The guidance aims to help professionals understand what they need to do, and what they can expect of one another, to safeguard children. It focuses on core legal requirements and it makes clear what individuals and organisations should do to keep children safe. In doing so, it seeks to emphasise that effective safeguarding systems are those where: the child s needs are paramount, and the needs and wishes of each child, be they a baby or infant, or an older child, should be put first, so that every child receives the support they need before a problem escalates; all professionals who come into contact with children and families are alert to their needs and any risks of harm that individual abusers, or potential abusers, may pose to children; all professionals share appropriate information in a timely way and can discuss any concerns about an individual child with colleagues and local authority children s social care; high quality professionals are able to use their expert judgement to put the child s needs at the heart of the safeguarding system so that the right solution can be found for each individual child; all professionals contribute to whatever actions are needed to safeguard and promote a child s welfare and take part in regularly reviewing the outcomes for the child against specific plans and outcomes; LSCBs coordinate the work to safeguard children locally and monitor and challenge the effectiveness of local arrangements; September 2017 Public Board

15 when things go wrong Serious Case Reviews (SCRs) are published and transparent about any mistakes which were made so that lessons can be learnt; and local areas innovate and changes are informed by evidence and examination of the data. 4. SOMERSET SAFEGUARDING CHILDREN BOARD 4.1 The 2004 Children Act required each Local Authority to establish a Safeguarding Children Board (SCB). Somerset Safeguarding Children Board (SSCB) was established in October The SSCB is the key statutory mechanism in Somerset for agreeing how relevant organisations will co-operate to safeguard and promote the welfare of children. 4.3 In March 2016 the Wood report was published. This was a review of the role and functions of the SCBs commissioned by the Government with the aim of strengthening multi-agency partnerships to safeguard children. In May 2016 the Government published a formal response to the Wood recommendations, detailing the actions they would take: To ensure engagement of the key partners in a better coordinated, more consistent framework for protecting children, we will: Place a new requirement on three key partners, namely local authorities, the police and the health service, to make arrangements for working together in a local area. This would not change the existing statutory functions or duties on any of the agencies individually, but it will require more robust and much clearer arrangements to promote effective joint working, in relation to safeguarding and promoting the welfare of children. To ensure these arrangements are multi-agency in their approach, we will: In addition to the new duty on the three key agencies, place an expectation on schools and other relevant agencies involved in the protection of children, to cooperate with the new multi-agency arrangements. The leaders from the three key sectors will be able to call on the support and cooperation of partner agencies, to form a clearer picture of how agencies are performing, and to make evidencebased decisions on how to achieve the best possible outcomes for children. September 2017 Public Board

16 To simplify and strengthen the existing statutory framework around multiagency working, we will: Remove the requirement for local areas to have LSCBs with set memberships, often leading to large and unwieldy boards. Local areas that have strong and effective arrangements for multiagency co-operation delivered through their LSCB will be able to retain them as long as they meet the new requirements. That means that the three key partners will take the decision to continue the arrangements because they see this as the most effective form of securing coordination. However they will be able to take advantage of much greater flexibility in developing arrangements that respond to local need and in which agencies are better invested. That flexibility will enable joint identification of and response to existing and emerging needs and priorities and improve outcomes for children. To ensure that local areas have robust arrangements in place for how the key sectors will work together, we will: Bring forward legislation to underpin the new arrangements. We will support this with statutory guidance and we will work with the inspectorates to establish suitable review arrangements. Require the three key sectors to establish governance arrangements and decide a range of issues, including the following: o o o o o the area or region which should be covered under the joint arrangements; how they will involve and work with other agencies who have a key role in protecting children; a plan setting out details of the arrangements, which they will publish; resourcing for the arrangements; how they will ensure a strong degree of independent scrutiny of the arrangements. In cases where local arrangements do not work effectively, we will: Provide for the Secretary of State to have power to intervene in situations where the three key agencies cannot reach an agreement on how they will work together, or where arrangements are otherwise seriously inadequate. Replace the current system of SCRs and miscellaneous local reviews with a system of national and local reviews in order to: September 2017 Public Board

17 o o o o o bring greater consistency to public reviews of child protection failures; improve the speed and quality of reviews, at local and national levels, including through accrediting authors; make sure that reviews which are commissioned are proportionate to the circumstances of the case they are investigating; capture and disseminate lessons more effectively, at local and national levels; make sure lessons inform practice. In order to make a centralised system work effectively, we will legislate to: Establish an independent National Panel which would be responsible for commissioning and publishing national reviews and investigate the most serious and/or complex cases relating to children in circumstances which the Panel considers will lead to national learning; Require Local Safeguarding Children Boards (and their successor arrangements) to carry out and publish the lessons from local reviews into cases which relate to a child or children in the local area and which are likely to lead (at least) to local learning. Taken from The Government s response to Alan Wood CBE, (DfE, May 2016) 4.4 The 2015 OFSTED Inspection, (see also Paragraph 13.2 above), found for a second time the Board s function to be inadequate. A further inspection is likely in 2017/2018 and the Board is currently undertaking an intensive programme of improvement measures. The Head of Safeguarding & Named Nurse have been assisting with these improvement measures and are involved in several Board Sub Groups and task and finish groups to address the improvements required. 4.5 The Head of Safeguarding is the Trust nominated representative on the Board. 4.6 The Board has specific Sub Groups for Education, Quality and Performance, Learning and Improvement, and Child Sexual Exploitation. The Trust Named Nurse was asked to chair the Learning and Improvement Sub Group by the Director of Children s Services in November Furthermore Somerset Partnership is represented on all of the Sub Groups by either the Head of Safeguarding or Named September 2017 Public Board

18 Nurse. In addition the Health Advisory Group is an additional group of the SSCB that brings together all of the Safeguarding professionals from all the NHS Trusts in the county including Somerset representatives from the South West Ambulance Service NHS Trusts, and the regional office of NHS Direct. This is attended by the Trust Head of Safeguarding, Named Nurse, and Named Doctor. 4.7 The SSCB receives regular statistical reports in relation to child protection processes and county wide child protection activity. The performance data below, (Tables 1-6), relate to the data provided to the SSCB by the Local Authority. 4.8 Tables 1 and 2 illustrate a 10% increase in the number of conferences convened in 2016/2017. This indicates a partial reversal of last year s decreasing numbers and correlates with the Public Health Nursing performance data discussed below. Significantly the overall trend of conferences convened continues to rise and is almost double the figures in 2013/2014. Please note this data illustrates the numbers of conferences convened rather than the number of children subsequently made subject to a Child Protection Plan. Table 1: Numbers of Child Protection Case Conferences convened /2010 Mendip Sedgemoor South Somerset Taunton All Initial Review Total South 2010/2011 Mendip Sedgemoor Somerset Taunton All Initial Review Total South 2011/2012 Mendip Sedgemoor Somerset Taunton All Initial Review Total South 2012/2013 Mendip Sedgemoor Somerset Taunton All Initial Review Total South 2013/2014 Mendip Sedgemoor Somerset Taunton All Initial Review September 2017 Public Board

19 Total South 2014/2015 Mendip Sedgemoor Somerset Taunton All Initial Review Total South 2015/2016 Mendip Sedgemoor Somerset Taunton All Initial Review South 2016/2017 Mendip Sedgemoor Somerset Taunton All Initial Review Total Table 2: Numbers of Child Protection Case Conferences convened Tables 3 and 4 illustrate the numbers of children subject to a Child Protection Plan by month. As this figure fluctuates on a daily basis data is calculated on the last day of each month for data accuracy. The mean figure illustrates an upward trend. September 2017 Public Board

20 Table 3: Numbers of Children Subject to a Child Protection Plan by month January February March April May June July August September October November December Mean Table 4: Numbers of Children subject to a Child Protection Plan by Month Tables 5 and 6 continue to illustrate that emotional abuse and neglect are responsible for the highest number of children requiring a Child Protection Plan. It is particularly noteworthy that there has been an September 2017 Public Board

21 80% increase in the number of children who are subject to a Child Protection Plan as a result of neglect. Recognition and management of neglect is one of the Somerset Safeguarding Children Board s five key priorities. Raising awareness of neglect is part of that process so it is not surprising to see a rise in the number of children identified as neglected. The SSCB are currently developing a multi-agency Neglect Strategy to coordinate services to respond to cases of neglect. Table 5: Children subject to a Child Protection Plan, by abuse category, illustrated as percentages as at 31 st March 2017 Category 2017 initial category of abuse 2017 latest category of abuse 2016, 2015 numbers of children 2017 % initial category 2017 % latest category Emotional , 46 19% 22% Neglect ,180 68% 70% Sexual , 22 3% 1% Physical ,13 2% 2% Multiple , 62 9% 6% Total , % 100% 2016, 2015, 2014, 2013 % Numbers of children 31%, 6%, 46%, 48% 57%, 34%, 27%, 29% 0.3%, 4%, previous data unavailable 4.7%, 3%, previous data unavailable 7%, 12%, 19%, 18% September 2017 Public Board

22 Table 6: Children subject to a Child Protection Plan, by abuse category as at 31 st March CHILD PROTECTION ACTIVITY 5.1 Public Health Nursing Child Protection Activity data is collated by the Named Nurse to provide assurance evidence for Care Quality Commission Outcome 7 and to identify trends which inform future training and policy / practice development, (Appendix 1). This data has been consistently collated since 2008 and the data reported continues to illustrate overall the upward trends which have also been reported anecdotally by both our staff and other agencies. This data also concurs with figures from the Somerset Safeguarding Children Board. 5.2 Attendance at Child Protection Conferences, (Table 7), by the Public Health Nursing Service is monitored on a quarterly basis by the Named Nurse. Overall attendance for the year has been 55%, 4% less from the previous years data. These figures continue to be affected by the change in policy in relation to the School Nursing Service who attend Initial Case Conferences and Review Case Conferences only when they are actively working with the subject of the conference or an health need has been identified that the School Nursing service need to address. However the Board should be assured that Public Health Nursing are providing reports to 86% of the conferences they have been invited to suggesting they are informing conference processes even if they are not attending the conference themselves. 5.3 It is also notable that there has been another substantial rise in the overall number of invitations to case conferences received by Public Health Nursing staff 825 in 2016/2017 compared to 650 in 2015/2016 September 2017 Public Board

23 although less than the 913 received in 2014/2015. The ongoing variations in this data are likely to be due to further embedding and increased staff knowledge of the SSCB Threshold Guidance and the ongoing Improvement agenda within Children s Social Care. Table 7 also illustrates that whilst activity is increased overall compared to five years ago the overall trend is slightly decreased. Review of the 2017/2018 data may give further clarity in regards to the overall trends. Table 7: Attendance at Child Protection Case Conferences Numbers of Core Group meetings attended by Trust staff has increased significantly to 737 in 2016/2017 compared to 687 in 2015/2016 and 535 in 2014/2015, (Appendix 1). This data would seem to clarify anecdotal information from staff about increasing workload in terms of key child protection duties and with the data illustrating a rise in child protection conferences, given core group meetings are called when a child has been given a Child Protection Plan at a child protection conference. 5.5 Appendix 1 also illustrates that numbers of all multi-agency meetings called in 2016/2017 has increased, a trend also noted in 2015/2016. This is likely due to the additional robustness of the Threshold Guidance which is facilitating improved identification of children in need and children at risk. Of particular note is the large increase in multi-agency meetings called by Somerset Partnership staff, suggesting staff understand and are utilising the Named Professional role and working within the Early Help agenda. September 2017 Public Board

24 5.6 Referral and assessment trends are also monitored by the Named Nurse. Audit evidence illustrates a continuing downward trend in the number of Level 4 referrals made to Children s Social Care. This is as a direct result of a significant piece of work completed by the Safeguarding Children Team working with Children s Social Care First Response Manager to review all referrals made by Trust staff and to better understand the rationale for referrals being rejected or accepted in line with the Threshold Guidance. As a result of this work, whilst the overall number of referrals made to Children s Social Care has decreased, the number of referrals accepted by Children s Social Care has significantly increased from 42% to 85% over a six month period. This figure clearly indicates that the number of referrals made by Trust staff meet the threshold of a level 4 referral suggesting that both staff and the Safeguarding Children Team have embedded the Threshold Guidance. Table 8: Referrals to Children s Social Care Contributions to Child and Family (Initial), and Section 47, (Core) Assessments reversed the trends of the previous year having decreased and increased respectively in respect of the overall totals of assessment Trust staff have contributed to. The increased number of Section 47 contributions is likely to be due to the increased involvement Trust staff have had in Strategy discussions, particularly those tasked with assessing if the threshold for Initial Child Protection Case Conference has been reached. The decreased number of Child and Family assessments could in part be due to the number of Early Help Assessments being completed across all agencies in Somerset and increasing numbers of Team Around the Child/Team Around the School meetings being implemented that are providing early interventions to children and families and halting an escalation to child protection. September 2017 Public Board

25 5.8 The number of reports prepared by staff for Public Law Outline proceedings and Child and Family Law proceedings has levelled out. In recent years there was a substantial increase in the amount of reports completed as Children s Social Care required additional evidence that thresholds were met when preparing cases for Court. It should be noted that the provision of Health information into court proceedings is a positive measure that is protective of the children and young people who are subject to the proceedings; giving the Court an opportunity to address any unmet health needs to ensure the child s wellbeing is protected. Table 9: Initial (Child and Family) Assessment Contributions September 2017 Public Board

26 2008/09 Q2 Q4 Q1 Q3 2010/11 Q2 Q4 Q1 Q3 2012/13 Q2 Q4 Q1 Q3 2014/15 Q2 Q4 Q1 Q3 2016/17 Q2 Q4 P Table 10: Section 47 (previously Core) Assessment Contributions Core (Section 47) Assessment Contributions - verbal and written Verbal Written 5.9 Trust staff child protection activity data is monitored by the Trust Safeguarding Steering Group, Safeguarding Children Best Practice Group and Children and Young People s Division Management Meeting. Exceptions are also reported to the Trust Clinical Governance Group on a quarterly basis In recognition of the increasing amount of involvement in child protection proceedings by CAMHS staff the Named Nurse has begun collecting data relating to CAMHS child protection activity. Whilst there is not enough data to provide any comparative results the activity figures are illustrated at Appendix Figures depicting numbers of current child protection clinical supervision cases and domestic abuse notifications received by the Public Health Nursing service are collated by the Named Nurse, (Appendix 3). This information is shared with the Public Health Nursing Managers to ensure that skilled staff members are deployed responsively to the areas of greatest need and consideration is given to the manageability of caseloads in terms of the level of child protection activity. The data is also shared with the Public Health Nursing commissioners to provide an overview of staff activity. 2016/2017 data illustrates a slight decrease in last year s significantly increasing trend in terms of open clinical supervision cases. This is likely to be due to the further embedding of the Early Help offer and increased staff knowledge and understanding of the SSCB Threshold Guidance. Domestic abuse notifications received have shown a further significant increase in this reporting period which aligns to the activity reported by the Police and Children s September 2017 Public Board

27 Social Care in terms of their overall activity for the county. It also reflects the increasing number of notifications shared with the School Nursing teams. 6. SAFEGUARDING ARRANGEMENTS WITHIN SOMERSET PARTNERSHIP Board Lead and Assurance Arrangements 6.1 The Director of Nursing and Patient Safety is the Executive lead with responsibility for safeguarding children. 6.2 The Trust has a nominated Non-Executive Director who takes responsibility for both adult and children s safeguarding. Following concerns raised by the Head of Safeguarding in relation to the nominated Non Executive Director s time available to support the service with the Trust s safeguarding agenda the responsibility was moved to another Non-Executive Director who has attended several Steering Group meetings and has taken an extremely proactive role in supporting and promoting the Safeguarding Service, particularly in respect of planned service developments. 6.3 The Trust has an integrated Adults and Children Safeguarding Steering Group which is chaired by the Head of Safeguarding. The groups Terms of Reference were reviewed, updated and ratified in December 2016 and are as follows: 6.4 The purpose of the Somerset Partnership Safeguarding Steering Group meeting is to: monitor and review safeguarding processes for both children and adults at risk, MARAC, MAPPA and PREVENT; identify any risks within Somerset Partnership services and take appropriate action; receive and review reposts from Best Practice Groups; monitor progress on internal/external action plans to ensure actions met within guidelines and specified timeframes; promote and encourage operational services to disseminate lessons learnt to appropriate staff / Best Practice Groups and make recommendations for service improvements as appropriate; monitor serious untoward incidents that relate to safeguarding children and adults at risk; September 2017 Public Board

28 develop and implement a rolling programme of audit based on national and local policy and the Trust s annual clinical audit programme to ensure that agreed safeguarding standards are maintained and to ensure improvements in systems and practice; develop and agree action plans in relation to audits and as a result of clinical incidents to address other key issues and achieve effective implementation of both child and adult safeguarding policies; evaluate effectiveness of action plans and outcomes; submit and receive information from the Local Safeguarding Children Board and Local Safeguarding Adults Board and their sub-groups Membership of the Steering Group includes the Trust Head of Safeguarding, Named and Designated professionals for Safeguarding, Head of Division, Children and Young People s Services, representation from both Adult Services and Mental Health Services. 6.5 Outcomes and learning from Serious Case Reviews and other serious and Near Miss incidents are monitored monthly at the Divisional Management Meeting for Children and Young People s Services and quarterly at the Safeguarding Steering Group, Clinical Governance Group, Serious Incidents Requiring Investigation Group, and Safeguarding Children Best Practice Group. 6.6 The Safeguarding Children Best Practice Group has met quarterly since September The group is chaired by the Trust Named Nurse. The Best Practice Group reports to the Safeguarding Steering Group and the Clinical Governance Group. It is responsible for: ensuring that policies, protocols and clinical practice for child protection within the Trust are fit for purpose and reflect current best practice and research; ensuring that mechanisms exist to monitor the effectiveness of child protection policies, protocols and practices within the Trust; monitoring the progress of: o o o action plans developed from Internal Health Community Reviews; Local Safeguarding Children Board action plans in relation to Serious Case Reviews; serious untoward incidents that relate to child protection; September 2017 Public Board

29 that lessons to be learned are disseminated to staff in order to improve and develop practice; developing, implementing and monitoring a rolling programme of audit based on national and local policy to ensure that agreed safeguarding and child protection standards are maintained and to ensure improvements in systems and practice; developing and agreeing action plans in relation to audits and as a result of clinical incidents to address other key issues and achieve effective implementation of safeguarding and child protection policies; making recommendations for service improvements; report to and receive information from the Safeguarding Steering Group; report to and receive information from the LSCB and its subgroups. Named Professionals for Safeguarding Children 6.7 The Named Nurse works closely with a team of three Locality Safeguarding Children Nurses in order to provide safeguarding children and child protection cover for each of the four geographical areas and to support the Multi Agency Safeguarding Hub, (MASH), (see below). 6.8 The Named and Locality Safeguarding Children Nurses provide child protection casework supervision, advice and support on a planned and ad hoc basis to all Trust staff. They also deliver a comprehensive training package across the Trust. 6.9 The Named Doctor s role and job description was reviewed in 2016/2017 by the Trust Medical Director. This process provided an opportunity to refocus the Named Doctor role in terms of the training and supervision of Trust medical staff. The Named Doctor remains a key member of the Trust Safeguarding Steering Group and Safeguarding Children Best Practice Group The Designated Nurse, (who is employed by Somerset Clinical Commissioning Group), has a role in clinical supervision of the Named Nurse, and also acts as an expert safeguarding children resource to the Named and Locality Safeguarding Children Nurses Management supervision of the Named Nurse is undertaken by the Head of Safeguarding who also leads Integrated Safeguarding Service meetings, reinforcing the Think Family approach to safeguarding. September 2017 Public Board

30 6.12 The Designated Doctor post is currently vacant and recruitment is underway. When appointed the post holder will provide clinical supervision and act as an expert safeguarding children resource for the Named Doctor The Named Nurse provides six weekly child protection and line management clinical supervision to the Locality Safeguarding Children Nurses The Named Nurse also provides six weekly child protection clinical supervision to the Children Looked After Specialist Nurse and to the Specialist Sexual Health Nurse for Children and Young People Child protection clinical supervision is provided to the Children Looked After Nurses by a Locality Safeguarding Children Nurse The quality of practitioner s records, referrals to Children s Social Care, contributions to multi-agency assessments and reports for Child Protection Conferences by Trust staff are monitored on an ongoing basis by the Named and Locality Safeguarding Children Nurses as part of the child protection clinical supervision arrangements The Named and Locality Safeguarding Children Nurses review the electronic records of CAMHS and Public Health Nursing Services on both an ad hoc basis and as part of the three monthly child protection clinical supervision process to ensure practitioners record keeping is of a high standard. If there are any concerns relating to professional practice they are discussed with the practitioner, the line manager and an agreed action plan is developed to address the issues concerned. The 2016/17 Public Health Nursing Documentation Audit included review of key child protection documentation processes. Data collection for this audit took place in March 2017 and the report is expected in early 2017/2018. Somerset Multi Agency Safeguarding Hub, (MASH) 6.18 Since September 2014 Somerset Partnership Safeguarding Children Nurses have taken a full role in the establishment of the Somerset Multi Agency Safeguarding Hub, (MASH) Serious Case Reviews consistently identify that professional information sharing processes are poor and key information is not shared in a timely manner or with the relevant professionals and agencies. The MASH is made up of professionals from Children s Social Care, the Police and Somerset Partnership who work together on a daily basis to share information about vulnerable children and young people to ensure good quality safety plans are developed and implemented to protect them from harm. September 2017 Public Board

31 6.20 The part played by the Trust in contributing to the MASH has increased significantly in the last year. As a result the Trust Locality Safeguarding Children Nurses trialled both a weekly and monthly rotation into the MASH to determine which was the most efficient and effective use of their time given their clinical caseload work streams. They collectively took the decision that a weekly rotation was the most beneficial, meaning that they did not spend as large a period of time away from their other clinical responsibilities The MASH role also includes management of the Trust safeguarding children generic box and of ad hoc queries that are telephoned into the team. It is recognised that 2016/2017 ha been the busiest year yet in terms of staffing the MASH and duty role. Whilst it has been an extremely positive role there continues to be some misinterpretation of the role of the Nurses on the part of some multi-agency partners who incorrectly assume they represent the whole of the Somerset Health community rather than Somerset Partnership only on a monthly basis whilst keeping responsibility for their own clinical area. In order to accommodate this role it was necessary to increase child protection clinical supervision intervals to three monthly from two monthly. It is accepted that this is the maximum safe limit for Trust staff who complete the most child protection work, i.e., Health Visitors and School Nurses The initial monthly MASH Management meetings held between the Trust Head of Safeguarding, Named Nurse and corresponding mangers from Somerset Direct and the Police to ensure the smooth running of the MASH process have become three monthly as the MASH process has successfully embedded. Information sharing has also improved during 2016/2017. Recent Children s Social Case audits have highlighted that the majority of cases discussed in the MASH have been appropriately uploaded to the relevant Somerset Partnership clinical records The ongoing integration of adults and children s safeguarding teams within the Trust continues to support a more efficient way of working with no duplication of safeguarding roles. This in turn has freed up staff time to fully participate in MASH, MARAC, (Multi Agency Risk Assessment Conference), and MAPPA, (Multi Agency Public Protection Arrangements), processes. 7. POLICIES AND COMMUNICATION 7.1 Agencies across the South West are signed up to one set of Child Protection Procedures that are maintained as an up to date resource for all staff to use. The procedures set the standard for good practice and are underpinned by evidence from research. This promotes uniformity of practice in child protection across the region. September 2017 Public Board

32 7.2 The web-based multi-agency South West Child Protection Procedures, ( remain in place. There has been a move by the Somerset Safeguarding Children Board to publish all Somerset multi agency child protection policies and procedures on the SWCPP site in preference to the Somerset SCB website, ( ), although they can be accessed by Somerset Partnership staff from both sites and from a link on the Trust Safeguarding Children intranet pages. All amendments and additions to policy are agreed by a regional steering group and any changes in practice are disseminated to Trust staff by the Named Nurse via s, memorandum, briefing papers, articles in the online staff magazine and updates to policy and guidelines. In 2016/2017 the following SSCB policies and procedures were developed, reviewed and uploaded: Effective Support for Children and Families in Somerset Guidance, (Formerly the Threshold Guidance), published November 2016 and including the updated referral process the Early Help Assessment Working Together Partnership Protocol updated August 2016 Pre Birth Protocol Version 2 updated October 2016 Resolving Professional Differences Protocol, (formerly Escalation Policy) updated October The following Trust Policies, Protocols and Guidance have been developed, ratified and disseminated to staff in 2016/2017: Safeguarding and Protection of Children Policy Following the first Trust PREVENT Safeguarding Adults Audit it was noted that the policy did not contain any information in relation to radicalisation and extremism. This has now been included; Sexual Assault Disclosures made by Children and Young People Policy This policy was updated to include reference to the new official definition of Child Sexual Exploitation and update of screening processes to include more generic reference to screening processes and to include reference to the newly developed Trust CSE Quick Guide Child Sexual Exploitation Policy As above also updated to include the new CSE definition, screening processes and Quick Guide September 2017 Public Board

33 Managing Historic Allegations of Child Abuse and Neglect Policy This policy was updated to include the addition of Home Office Crime Reporting Rules, (HMGov, April 2016) Both the Trust Safeguarding Strategy and Domestic Abuse Policy have been under review in 2016/2017 and are expected to be ratified in 2017/ SAFEGUARDING CHILDREN TRAINING 8.1 Somerset Partnership NHS Foundation Trust has had a clear Safeguarding Children Training Strategy detailing all levels of safeguarding training available to staff and clear instructions to indicate which staff groups require which level of training. In 2016/2017, in line with the ongoing development of a Trust integrated Safeguarding Service, the Training Strategy has been completely redeveloped to include safeguarding adults training requirements. The Strategy is currently being finalised with a plan to present to the Clinical Policy Review Group in April The majority of safeguarding children training is provided by the Named Nurse and Locality Safeguarding Children Nurses through taught sessions delivered at a variety of venues across the county. More than 600 training places are provided by the Team annually. 8.3 In 2016/2017 the Named Nurse conducted an in depth training needs analysis to determine which staff required with level of training in line with both recommendations from the 2015 CQC Review of Children Looked After and Safeguarding Services in Somerset and from the Intercollegiate Document Safeguarding children and young people: roles and competences for health care staff, (RCPCH, 2014). As a result the numbers of staff requiring both Level 2 and Level 3 training increased significantly, requiring additional training sessions to be arranged and decreasing the Trust s overall safeguarding children performance data. 8.4 On 31st March 2017 training attended figures were as follows, (figures at 31 March 2016, 2015, 2014, 2013 and 2012 in brackets): Level %, (96%), (95%), (96%), (94%) (93%) Level %, (95%), (93%), (91%), (92%) (72%) Level %, (93%), (95%), (87%), (87%) (83%) Tables 11 and 12 below illustrate that whilst the inclusion of new staff groups at level 2 and 3 initially decreased overall performance figures to 46.4% and 71.0% respectively, the subsequent increase illustrates an upward trend whereby level 2 has returned to its previous high level of September 2017 Public Board

34 achievement and Level 3, whilst taking longer to achieve is also close to a Green ranking. 8.5 Overall safeguarding children training levels have risen and been sustained, (Table 11). Managers receive monthly information regarding training compliance and are required to ensure all staff book onto training three months before their expiry date becomes due. Table 11 Safeguarding Children Training Rates by Quarter 2016/2017 Table 12 Safeguarding Children Training Rates 2016/ Training continues to be provided through a mix of via face to face taught modules, e-learning and test your knowledge sessions. For those staff who require Level 3 training multi-agency training is required on a three yearly basis. This is delivered by the Somerset Safeguarding Children Board. Since 2015 there has been a charge for this training but as Trust staff contribute as trainers to several different SSCB training courses an agreement was reached in 2015/2016 that SSCB September 2017 Public Board

35 training would continue to be free at the point of delivery for Trust staff. Furthermore in 2016/2017 the Trust Head of Safeguarding, Named Nurse and Locality Safeguarding Children Nurses all accessed Barnardo s Child Sexual Exploitation Train the Trainer courses on the understanding they would deliver SSCB CSE courses in the coming year. Both the Head of Safeguarding and the Named Nurse have multiagency training sessions booked in 2017/2018 to deliver this highly regarded training programmed on behalf of the SSCB. 8.7 Two new modules of Level 3 training have been successfully developed in 2016/2017 and were rolled out to staff in January One module relates to the most recent Serious Case Review Baby Sam and the other is a new Child Sexual Exploitation, (CSE), module which explores the themes emerging from both the ongoing Somerset CSE Serious Case Review Operation Fenestra and from other local CSE cases to ensure staff understand both the national picture of CSE and the impact within Somerset with the aim of increasing awareness of CSE and of the CSE screening and risk assessment process. 8.8 Additional bespoke training has been provided to CAMHS staff by the Head of Safeguarding in relation to Child Sexual Exploitation. The Named Nurse has delivered attended two bespoke Level 3 modules Identifying and Managing Risks and Protective Factors in Child Protection Case Work and Record Keeping and Report Writing in Child Protection Case Work to those student Health Visitors undergoing training. The Named Nurse has also provided a bespoke training session to the whole of the Public Health Nursing workforce at their annual Away Day which included lessons from recent Serious Case Reviews and other significant learning from complex cases. 9. APRIL 2015 REVIEW OF CHILDREN LOOKED AFTER AND SAFEGUARDING SERVICES IN SOMERSET 9.1 As reported in the previous Annual Report the Care Quality Commission contacted Somerset Clinical Commissioning Group on 16 th April 2015 to announce that they would be conducting a review of how health services in Somerset keep children safe and contribute to promoting the health and wellbeing of looked after children and care leavers. The review took place between 20 th and 24 th April 2015 and considered 148 children, young people and care leavers. Staff and managers from across Somerset Partnership were involved in the review. 9.2 The final report by CQC was published on 8 December 2015 and the Trust Named Nurse developed a wide ranging and comprehensive overarching action plan to address the issues raised by CQC and implement the recommendations. September 2017 Public Board

36 9.3 The ongoing action plan was reviewed by NHS England and Somerset Clinical Commissioning Group in May 2016 and assessed as good. At that time there were three outstanding actions: the development of an integrated Trust Safeguarding Training Strategy; ongoing work to improve the standards of Children Looked After Health Assessments and to ensure there are robust governance arrangements in place; audit of CAMHS care plans to ensure there has been an overall improvement in their quality. With the exception of the Integrated Trust Safeguarding Training Strategy, (which was sent for ratification in April 2017), the action plan was completed in October A full review of all Trust services took place in March 2017 as discussed at paragraph 3.11 above. The Local Authority is expecting a further OFSTED inspection following the monitoring visit OFSTED undertook in November 2016, (see also paragraph 3.12 above). As for previous inspections and reviews the Trust Head of Safeguarding and Trust Named Nurse will work closely with Managers and staff to prepare for this event. 10. AUDIT 10.1 Audit of the quality of referrals to Children s Social Care (post April 2015 CQC Review) 10.1The 2015/2016 audit to review and monitor the quality of staff referrals to Children s Social Care illustrated significant improvements in quality and an increase in the number of referrals accepted by Children s Social Care from 42% at the beginning of May 2015 to 85% at the end of Quarter /2016. In November 2016 the Somerset Safeguarding Children Board, in partnership with the Local Authority launched an updated referral process in line with the Effective Support for Children and Families in Somerset Guidance. The previous referral process was replaced with the Early Help Assessment framework which included a completely new referral template and associated guidance As a result of this the planned re-audit of the quality of referrals was postponed to allow staff the opportunity to embed the new process. An updated audit tool was developed to reflect the new referral process and all referrals to Children s Social Care in Quarter /2017 were audited. The results are expected in Quarter / 2018 and an action plan will be developed and implemented to address any issues the audit identifies. September 2017 Public Board

37 10.3 All referrals will continue to be quality assured by members of the Trust Safeguarding Children Team prior to submission to Children s Social Care. Numbers of referrals are also kept under review to ensure staff are following the guidance for referral and are not leaving vulnerable children without the appropriate additional services they require. Section 11 Audit 10.4 In June 2016 the Trust took part in the two yearly Somerset Safeguarding Children Board audit to review arrangements to safeguard and promote the welfare of children in line with Section 11 of the Children Act For the first time the SSCB had commissioned an on-line audit tool to facilitate this process. Somerset Partnership provided assurance evidence to illustrate their self-assessment as Outstanding. The SSCB subsequently agreed to invite those agencies who achieved Outstanding status to a Peer Review Challenge meeting, requesting further evidence of excellence to be presented to a panel of strategic managers from across the multi-agency partnership. The Head of Safeguarding and Trust Named Nurse attending this meeting in April 2017 and were able to provide further assurance of their Outstanding status which the panel unanimously endorsed. Public Health Nursing Annual Documentation Audit 10.5 The Safeguarding Children Team have once again been part of the annual Public Health Nursing Annual Documentation Audit, in recognition of the significant part robust clinical records plays in safeguarding children. An audit tool was developed in January 2017 and the data collection took place in March Draft reports have been produced which illustrate the following strengths and areas for improvement: Strengths: 90% of records had a completed FHNA; care plans had the child(ren) as the main focus (87%) and clear timescales (95%); the structure of progress notes has improved from 75% in to 97% in 2017; 93% of records, where a telephone call is documented, had an agreed action plan; documenting recipients of shared information has increased from 75% in to 81% in 2017; progress notes had less abbreviations and spelling mistakes compared to results, but there is still improvement required in this area; September 2017 Public Board

38 medication names are written in full (93%). Areas for improvement: only 29% of records were complete in line with the NMC standard, with particular improvement required in the recording of: Confidentiality statement, details of early years settings (where appropriate), father s name and/or partner s name; FHNA should be updated at each core contact and after every significant change. Currently this happens for 73% and 79% of records respectively; only 59% of Universal Plus or Partnership Plus families had a personalised care plan/plan of care; all relevant risk screens should be completed for clients; medication should be written in capitals; clinicians must populate their RiO diaries in full. An action plan is currently being developed to address the issues and ensure the recommendations are fully implemented. The action plan will be monitored at the Public Health Nursing Best Practice Group which is attended by the Trust Named Nurse. 11. CHILD DEATH REVIEW 11.1 From April 2008 all LSCBs had a statutory duty to hold a child death review when a child dies. Chapter 5 in Working Together to Safeguard Children (DFE, 2013), sets out the procedures to be followed when a child dies The deaths of all children under 18, (excluding all stillbirths or planned terminations), are reviewed by the Child Death Overview Panel (CDOP) to ensure there is full understanding of events and identification of any factors which would prevent similar deaths in the future. Health Visitors are required to complete a Form B which provides comprehensive information on the baby/child for the panels to review The Wood Report as part of the review into the role and function of Safeguarding Children Boards, (see also paragraph 4.2 above), has recommended the introduction of a national database for CDOPs and for the Department of Health to determine how CDOPs can be organised on a regional basis with sub-regional structures to promote learning and dissemination. Consideration will also be given to the membership of CDOP to ensure appropriate representation from both health and non-medical agencies. The Somerset Safeguarding September 2017 Public Board

39 Children Board is currently awaiting the publication of statutory guidance by NHS England in respect of CDOP requirements During the year 2013/2014 there were 35 Somerset child deaths, the same number as for 2012/ deaths have been reviewed, 2 of which were from out of county. During 2014/2015 there were 39 child deaths of which 30 have been reviewed at the CDOP. During 2015/2016 there were 26 child deaths. 37 child deaths have been reviewed at the CDOP 11.5 During 2016/ 2017 there were 24 child deaths. 27 child deaths have been reviewed at the CDOP, (Table 12). Table 12 Child Deaths As numbers of deaths reviewed in Somerset are small, statistical analysis is difficult. However the following themes have been identified and shared with relevant Trust staff: unsafe sleeping arrangements for infants including bed sharing, sleeping in car seats or on sofas, and drug and alcohol usage by parents; failure to use the Pre Birth Planning Protocol; poor communication between secondary and tertiary care; children with asthma must have a personalised care plan. September 2017 Public Board