LUIGI: The review recommendations
The recommendations arising from the serious case review by the Suffolk Safeguarding Children Board.Health: A i. Health visitors should be reminded they must make referrals to Children and Young Peoples' services when they have any concerns about the safety and welfare of children.
The recommendations arising from the serious case review by the Suffolk Safeguarding Children Board.
A i. Health visitors should be reminded they must make referrals to Children and Young Peoples'
services when they have any concerns about the safety and welfare of children.
ii. Health staff must ensure they are made aware of the outcomes of referrals, if necessary by making
their own enquiries, and must record the outcomes on children's health visiting records.
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B i. All nursing staff should be reminded they must follow Nursing and Midwifery Council and Trust
standards, policies and procedures. Record keeping should be audited during supervision.
ii. All health visitors should be reminded a 'significant event form' must be in front of each child's
record, and be completed in accordance with trust standards.
C. i. All staff should be reminded that the safety and wellbeing of the children of the household must
always be paramount, particularly where domestic abuse is known or suspected to be taking place,
and their needs must be fully discussed in supervision.
ii. Health visitors should be reminded that safeguarding supervision is mandatory and must be
followed in accordance with Trust standards.
Ipswich Hospital NHS Trust:
D. To ensure all midwives have a good working knowledge of the Trust Domestic Violence
Identification and Management guideline, and the Department of Health publication 'Responding
to Domestic Violence: A Handbook for Health Professionals.'
E. To review the Trust's Domestic Violence guideline to include explicit guidelines as to relevant
agencies and support services that may be contacted, together with revision to ensure it is
compatible with the Department of Health guidance.
F. To consider the keeping of an information log located in medical notes, that is accessible to
Midwifery staff, but not patients, on which concerns or likely or known domestic abuse are
G. With key inter-agency partners, consideration should be given to implementing an escalation
strategy and robust pathway of communication.
H. To review the current practice whereby documentation relating to babies should be held in a
separate medical record with their own hospital number and not with mother's medical notes.
I. To review in Suffolk and East Norfolk the current practice of keeping a separate health record for
Accident and Emergency Department, and to invite the Department of health to consider the matter
at a national level.
J. i. GPs should be reminded in these situations the safety and wellbeing of the children in the household
must always be considered, and the emphasis of care shifted from the adult.
ii. GPs should be reminded to follow the advice of the Department of Health guidance on domestic
abuse, and if children are present in the household, follow the newly published guidance on child
protection provided by the General Medical Council, if necessary also consulting the Named Doctor
for Safeguarding Children.
K. GPs should be reminded that concerns about domestic abuse should be documented carefully to
allow significant events to be recorded, and action taken to ensure the safety of any children in the
household, in accordance with the Department of Health guidance on domestic abuse.
All Health Agencies:
L. Copies of the Department of Health publication 'Responding to Domestic Abuse: A Handbook for
Health Professionals should be made available to all frontline staff.
Children and Young People's Services:
M. i. All staff should be reminded they must ensure that all significant adults and relationships are
logged on to COMPASS (electronic recording system) in accordance with existing procedures.
ii. Social Care Services Managers should be instructed they must check this has been done before a
case is closed, and procedure should be amended accordingly.
N. Staff should be reminded:
i. Minimum agency checks, including Police checks, must be made on any referral involving
ii. Minimum agency checks must be made at the time of referral even if the Initial Assessment is
iii. As well as agency checks
Children and Young People's Services/Police
O. i. Staff should be reminded that decisions and the reasons for them should be agreed and clearly recoded in accordance with Suffolk Safeguarding Children procedures.
ii. When important issues between safeguarding agencies are not resolved through a strategy discussion, staff should be reminded they should immediately refer the matter to the Locality Manager, with the purpose of having an inter-agency discussion with Police at Senior Manager level.
P. i. Officers should be reminded to complete and submit Domestic Violence referral forms in all cases.
ii. Officers should be reminded to complete and submit Child Protection referral forms in all relevant cases.
iii. Current child abuse and domestic abuse training delivered to frontline staff should endorse the above findings.
Q. Letters informing applicants about decisions not to give priority to their application should be copied to the referring agency if there is one.
R. Ensure a training programme is delivered to all frontline staff.
Safeguarding Children Board:
S. i. Suffolk SCB should evaluate the training provided by the SCB and partner agencies in order to ensure the focus on the effects of domestic abuse on children is adequately addressed to safeguard and promote the welfare of children.
ii. Suffolk SCB should issue guidance on referrals by all agencies to Children and Young Peoples Services where domestic abuse is suspected, and on thresholds for commencing Child Protection (Section 47) enquiries.
T. i. Suffolk SCB should further promote collective responsibilities under Section 10 and Section 11 of the Children Act 2004 and Working Together to Safeguard Children 2006.
ii. Suffolk SCB should promote and support the establishment of the Multi Agency Risk Assessement Conference system (MARAC) countywide.
The Action Plan
Each agency has prepared an action plan in respect of the above recommendations, and their progress will be monitored by the Performance, Monitoring and Quality Assurance Group.