Lessons from Serious Case Reviews: Perinatal healthcare teams

Thursday, June 1, 2017

The NSPCC has analysed evidence from serious case reviews to identify learning. In this issue, we look at a summary of risk factors and learning for improved practice for the health sector.

Health professionals involved in perinatal care, such as GPs, midwives, health visitors, paediatricians and obstetricians are best placed to identify families who need early help to prevent situations deteriorating to the extent that the baby or young child is at significant risk of abuse or neglect.

Reasons case reviews were commissioned

This briefing summarises the learning from case review reports published between 2011 and August 2015.

In these case reviews, children died or suffered serious harm in a number of different ways:

  • Non-accidental injuries
  • Physical and emotional neglect.

Key issues in case reviews

Identifying and responding to concealed or denied pregnancy

Case reviews highlighted health professionals failing to recognise the significance of concealed or denied pregnancy and respond appropriately.

A woman may conceal or deny a pregnancy, or present for antenatal care at a very late point in her pregnancy, for a number of reasons some of which may make her and her baby very vulnerable. These include: learning difficulties; drug or alcohol misuse; mental illness; the pregnancy being the result of sexual abuse; or fear that revealing the pregnancy may provoke or worsen domestic abuse and violence.

Building relationships with families and being curious

It can be difficult to judge how much information to gather through routine interactions. Case reviews criticised practitioners for not being curious enough about a mother's circumstances - her history and family background, current circumstances, support networks and the details of male adults in the household. It is particularly important to be aware of how a mother's past experiences and current issues, for example mental health and housing, can impact on a baby's welfare. The quality of interactions depends on the health visitor's skill in building a good relationship with the mother that encourages her to be open.

One case review praised an area's requirement that health visitors complete a genogram of the child and family. Genograms provide a structured framework for discussion and a prompt to be inquisitive.

Working with families with complex needs

When professionals work with a very large number of families with similar complex needs, there is a risk that issues such as drug and alcohol misuse become "normal", making professionals less alert to the dangers they pose to babies and young children. Practitioners can also become accustomed to working in areas with high levels of street and drug-related violence. This "desensitises" them to safeguarding risks in the wider community.

Practitioners need to be aware of the risk that domestic abuse poses to babies. In addition to the potential risk of physical harm, there is evidence that domestic abuse has a significant emotional impact on babies due to the plasticity of their developing brains. The stress of domestic violence can also impact on parents' capacity to care for their babies.

When practitioners have to deal with parents who are hostile and aggressive, they sometimes focus too much on the parents and not enough on the impact this behaviour will be having on their babies.

Performing postnatal checks and development assessments

There was concern that in some cases GP postnatal checks were a tick-box exercise with not enough analysis of potential indicators of child neglect such as slow weight gain. GPs need to be vigilant to safeguarding risks and refer these to health visitors to investigate further.

Workloads, targets, timescales and supervision

Some case reviews flagged the issue of high levels of health visitor caseloads limiting the time professionals have to spend on visits and undertake thorough and reflective assessments. They are also under pressure to meet targets and work within stringent timescales. Such constraints result in superficial assessments and an incomplete analysis of the risks facing a vulnerable family who then miss out on vital support services.

Good supervision is essential in challenging practitioners to reflect critically on their judgments. Health professionals felt that due to the sheer volume of cases involved, their supervision had become too directive - checking that plans had been followed and targets and timescales met. This was at the expense of reflective, challenging supervision that was also supportive of the emotional demands of working with children and families.

Working with professionals in other agencies

Case reviews highlighted the issue of health practitioners not fully understanding or consistently applying the thresholds for statutory intervention, which resulted in high-risk families not being referred to children's social care.

There was also concern that health professionals and agencies were reluctant to assume lead responsibility for a family. This results in inadequate information sharing and a lack of co-ordination in the response of professionals from different agencies.

Information sharing

Good information sharing between professionals is essential to identify and support vulnerable families. Many case reviews flagged poor information sharing between professionals involved in perinatal care.

Pregnant women are able to access antenatal care either through the general practitioner or directly with the community midwife. In practice, this can result in a GP not knowing that their patient is pregnant. When GPs and midwives are not obliged to share information, there is some scope for women to fall through the net of services. Although it is rare, vulnerable women, who refuse to engage with services or may be denying or concealing a pregnancy, are particularly at risk of not receiving the care they need.

Some case reviews criticised the system of assigning health visitors to a geographical area rather than a specific GP. This can result in little or no information being exchanged between health visitors and family GPs.

Information sharing is also compromised when the full range of health professionals working with a family fail to attend child protection conferences and core groups. Absent GPs, midwives and paediatricians are not able to give first-hand accounts of their involvement with families, which leaves other members of the group to interpret information which can result in important nuances being lost.

Learning for improved practice

Responding to concealed or denied pregnancy

  • When there has been a concealed or denied pregnancy, midwives, health visitors and GPs need to work together with children's social care to record and investigate the circumstances in detail.
  • Consider the mother's psychological and psychiatric status. Ensure that therapeutic services are available to her and that she uses them.
  • NHS walk-in centres should always make sure pregnant women are receiving antenatal care and arrange for follow-up if necessary.

Finding out about the family

  • Train health visitors to use genograms to help with questioning around family circumstances, identifying main carers, and details about the birth father and other men in the household.
  • Health visitors should also ask questions about the family's social circumstances and the community in which they live.
  • Health visitors should record and share information gathered during assessment where relevant.

Working with families with complex needs

  • Give risk-assessment skills training to health professionals working with families with complex needs.
  • Include all family members in assessments. Consider historical information and cumulative concerns. Understand the risks posed by substance misuse, domestic violence and parental mental health. The child's needs should be a central focus of assessment at all times.
  • When assessing new mothers, consider the potential for coercive control within adult relationships.
  • Consider how to approach the issue of domestic abuse with expectant and new mothers who are always accompanied during medical appointments.
  • Be aware of cultural and religious sensitivities when working with some families.

Performing postnatal checks and development assessments

  • Educate and inform parents of the risks of non-accidental head injuries in babies.
  • Always remove the baby's nappy before weighing to get an accurate weight.
  • Make sure the baby's weight is plotted on the growth (centile) chart.
  • Analyse information and data gathered during the checks for potential safeguarding risks.

Sharing information and working collaboratively

  • When discharging mothers and babies from hospital, make sure that safeguarding concerns and social circumstances are communicated to health visitors and community midwives on the hospital discharge summary.
  • Make sure that information systems allow health professionals to share information easily and clearly.
  • Ensure that GPs and midwifery services share information about pregnant women to ensure they are receiving adequate antenatal care.
  • Ensure that health visitors are being routinely informed of pregnancies.
  • Train professionals in recognising the thresholds for referral to children's social care and when to call for a strategy meeting.

Supervision and workloads

  • Newly qualified health visitors should discuss all their complex safeguarding cases during supervision.
  • Experienced practitioners should bring three or four complex cases to supervision for in-depth discussion and analysis. Insight from these discussions can then be transferred to all cases with similar issues.
  • Supervisors should encourage their staff to reflect on the emotional impact of managing complex cases.
  • Health professionals should escalate failures in processes to managers so that action can be taken.
  • Consider ways to improve recruitment and retention of health visitors.


Health Visiting Briefing, Nice, September 2014

Safeguarding Children for Healthcare Professionals, RCPCH, September 2014

Safeguarding Children And Young People: Roles and Competencies for Healthcare Staff, intercollegiate document, March 2014

Safeguarding Children Toolkit for General Practice, RCGP

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