CP2(A). Pre-birth Referral and Assessment

1.1

Where agencies or individuals anticipate that prospective parents may need support services to care for their baby or that the baby may have suffered, or be likely to suffer, significant harm, a referral to local authority children's social care must be made as soon as the concerns are identified. See Responding to Concerns of Abuse and Neglect Procedure, Potential risk to an unborn child.

1.2

The importance of conducting pre-birth assessments has been highlighted by numerous research studies and case / practice reviews which have shown that children are most at risk of fatal and severe assaults in the first year of life, usually inflicted by their carers. It is important to consider the circumstances of both prospective parents, not just the mother. Where possible, information should be obtained directly from each prospective parent rather than relying on a third party account [1].

[1] See The myth of invisible men: safeguarding children under 1 from non-accidental_injury caused by male carers and Hidden men: learning from case reviews - NSPCC and Serious Case Review in relation to Clare and Ann – RBKC.

1.3

The following circumstances might indicate an increased risk to an unborn child. A referral should be made to children’s social care to decide if a pre-birth assessment needs to be undertaken.

• A child has previously sustained non accidental injuries in the care of either parent / carer (this includes the sudden, unexpected death of a child where safeguarding concerns were raised);
• Previous children in the family have been removed from the care of the parent(s) either by a private arrangement or by a court order;
• A child in the household is the subject of a Child in Need or Child Protection Plan or is a Looked after Child;
• Either parent is the subject of a Child in Need or Child Protection Plan or is a Looked after Child or Care Leaver;
• The mother is a child aged under 16 who is found to be pregnant (see Sexually Active Children Procedure and Sexual Exploitation Procedure);
• A parent or other adult in the household, or regular visitor, has been identified as posing a risk to children (see Risk Management of Known Offenders Procedure);
• There are concerns about the parent(s) ability to protect the baby;
• There are concerns regarding domestic violence and abuse (see Domestic Abuse Procedure);
• Either or both parents have mental health problems that might impact on the care of a child (see Mental Illness (Parenting Capacity) Procedure);
• Either or both parents have a learning disability that might impact on the care of a child (see Learning Disability (Parenting Capacity) Procedure);
• Either or both parents abuse substances; alcohol or drugs (see Parents who Misuse Substances Procedure);
• Any other concerns exist that the baby may be at risk of Significant Harm including a parent previously suspected of fabricating or inducing illness in a child (see Fabricated or Induced Illness Procedure) or harming a child;
• The mother had not registered for antenatal care;
• If the pregnancy is denied or concealed.

This list is not exhaustive, and professionals will need to apply their judgement.

For more information about risk factors, see “The myth of invisible men: safeguarding children under 1 from non-accidental injury caused by male carers”.

If a decision is made by the local authority not to undertake a pre-birth assessment following the referral, then this should be clearly recorded on each agency’s files together with the rationale for that decision.

1.5

If a decision is made by the local authority to delay the commencement of an assessment following a referral, then this should be clearly recorded on each agency’s files together with the rationale for that decision and a date set for that decision to be reviewed.

2.1

Where agencies or individuals anticipate that prospective parents may need additional support to care for their baby, they should clarify what they already know about the family and seek information from other agencies. They should clearly outline strengths within the family, their concerns in terms of how the parent's circumstances and / or behaviours may impact on the baby and what risks are predicted. It is important to note that:

• There can be a lack of patient record integration across the health service which may necessitate multiple requests for information and that some risk factors (especially those pertaining to fathers / partners) may only be known to GPs;
• Local authority information systems may need to be searched separately for information about adults and that requests for information may need to be made to more than one local authority if one of the prospective parents resides in a different area.

3.1

Proactive, effective information sharing is essential to identify, assess and respond to risks or concerns about the safety and welfare of children at any time and especially prior to birth. The General Data Protection Regulations (GDPR) provides a number of bases for sharing personal information including “legal obligation” and “public task”; consent is not required when seeking information nor when making a referral – see paragraph 4.12 in CP2, referral and assessment. Concerns should normally be discussed with prospective parents – see paragraph 4.1 below.

3.2

A multi-agency meeting under the local early help procedures may provide a forum for sharing information and to help identify a multi-agency package of support for the baby and family. This should take place as soon as possible but preferably not later than 18 weeks.

3.3

Compiling a full chronology and family history is particularly important in assessing the risks and likely outcome for the child. Professionals should try to compile a clear history from the parents about their own previous experiences in order to find out whether they have any unresolved issues that may impact on their parenting of the child. It is important to find out their feelings towards the new-born baby and the meaning that the child may have for them. It is also important to find out the parents’ views about any previous children who have been removed from their care and whether they have demonstrated sufficient insight and capacity to change in this respect.

3.4

Pre-Birth Assessment is a sensitive and complex area of work. Parents may feel extremely anxious about their child being removed from them at birth. Referring professionals may be reluctant to refer vulnerable adults and be anxious about the prospective parents losing trust in them.

3.5

If there are concerns that the unborn baby may be at risk of significant harm, a referral should be made to Children’s Social Care at the earliest opportunity to:

• Provide sufficient time for a full and informed assessment;
• Enable the early provision of support services to facilitate optimum home circumstances prior to the birth;
• Enable the parents to have more time to contribute their own ideas and solutions to concerns and increase the likelihood of a positive outcome to assessments;
• Avoid initial approaches to the parents in the last stages of pregnancy, at what is already an emotionally charged time;
• Provide sufficient time to make adequate plans for the baby's protection.

4.1

Concerns should be shared with prospective parent(s) UNLESS in doing so the unborn child or a sibling will be at an increased risk of significant harm. In those cases, practitioners should liaise with their named / designated professional for safeguarding for advice and support.

4.2

If an urgent response is required if a pregnancy is concealed [1], or denied or the mother isn’t receiving antenatal care, a strategy meeting should always be convened.

[1] A concealed pregnancy is where the mother is aware that she is pregnant however conceals the pregnancy from family / friends and / or health professionals. The reasons for concealment can be varied however, should always present as a potential safeguarding concern. Case / Practice Reviews tell us that lack of engagement is a risk factor for potential significant harm. A referral to children social care should be made for all concealed pregnancies and the mother should not be discharged home until the outcome of the social care referral is known. Information should be obtained from the GP and other relevant agencies. A discharge planning meeting should be convened.

4.3

If the pregnant woman is not receiving ante-natal care, then her reasons for not doing so should be explored and attempts made to ensure she does receive ante-natal care and is booked in for delivery. There is an increased risk of serious obstetric and medical complications to mother and baby if they don’t receive ante-natal care, or they have late or only partial ante-natal care.

See

NICE Quality statement 5: Women with no antenatal care

BMC Under-attending free antenatal care is associated with adverse pregnancy outcomes

BMC Understanding delayed access to antenatal care

If a pregnant woman fails to attend antenatal appointments and cannot be located, information should be shared with maternity services in other neighbouring areas. Should a pregnant woman present at a different hospital from that which had provided her antenatal care seeking assistance / in labour, then the originating hospital maternity services should be contacted and asked to provide relevant information about any concerns / risk that they may have identified.

If a pregnant woman disengages from maternity services and the local authority had already commenced a pre-birth assessment, then they should be notified, and consideration given to what further action should be taken. It is a priority to re-engage the pregnant woman with maternity services in order to ensure the best possible outcomes for both the mother and baby. If concerns had been identified but a decision had not been undertaken to undertake a pre-birth assessment, then a further referral should be made to the local authority and that decision reviewed.

A pre-birth assessment should always be undertaken where prospective parents may need support services to care for their baby in addition to those available through early help services or where the unborn baby may have suffered, or be likely to suffer, significant harm.

Pre-birth assessments may be undertaken as an assessment of need; they may subsequently become an assessment of risk. Consideration should be given as to when during the pregnancy the child protection procedures are invoked to ensure the appropriate support and monitoring can be put in place sufficiently early.

The pre-birth assessment should usually commence as soon as possible after a viable pregnancy has been confirmed and the mother has registered for midwifery care, but no later than 16 weeks into the pregnancy. If the initial identification of the pregnancy is delayed or concealed, or the mother isn’t receiving ante-natal care it should commence as soon as the pregnancy has been identified. The assessment should identify:

• Risk factors;
• Family history and functioning;
• Always include the father of the baby;
• Strengths in the family environment;
• Factors likely to change, reasons for this and timescales.

It is important that social workers do not conduct assessments in isolation. Working closely with relevant professionals such as midwives and health visitors is essential. Liaising with relevant substance misuse, mental health and learning disability professionals is also crucial. The liaison mental health worker will also offer advice on cases with a mental health component and become involved in liaison with mental health professionals.

It is crucial to seek information about fathers / partners whilst conducting assessments and involve them in the process. It should not be assumed that a male partner is necessarily the father of the unborn child. Research suggests that paternal attendance at pregnancy scans and at births is over 90% indicating that fathers are there to be engaged [1]. Background police and other checks should be made at an early stage in relevant cases to ascertain any potential risk factors and necessary risk assessments undertaken. This can include mental health or substance misuse, for example. The Data Protection Act 2018 and General Data Protection Regulations (GDPR) do not prevent the sharing of information for the purposes of keeping children safe. Fears about sharing information must not be allowed to stand in the way of the need to promote the welfare and protect the safety of children (WT 2018).

[1] See the Myth of Invisible Men, cited above
[1] Research suggests that infants were more likely to be killed by their father (at a rate of approximately 2:1) than their mother. See: Flynn S, Shaw J & Abel K (2013) Filicide: mental illness in those who kill their children

Where fathers / partners do not engage and / or mothers do not provide their details, then this could provide a further reason to be concerned.

Working with extended families is also crucial to the assessment process and achieving positive outcomes for unborn children. Consideration should always be given to convening Family Group Conferences in any cases where there is a possibility that the mother may be unable to meet the needs of the unborn child.

Family Group Conferences can enable the families to be brought together to make alternative plans for the care of the child thus avoiding the need for Care Proceedings in some cases. Parallel assessment of alternative family carers can prevent delays in Care Planning for the child.

The assessment should consider the risk of sudden unexpected death in infancy (SUDI) [1] and how professionals will address these risks with the parent(s).

[1] Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm - The Child Safeguarding Practice Review Panel 2020 found that the risk factors known to increase the risk of SUDI were more likely to be present where children are considered to be at risk of significant harm.

The assessment should be completed within 45 days and must make recommendations regarding the need for a child in need planning meeting, a Pre-Birth Child Protection Conferences, or a legal planning meeting to consider initiating Public Law Outline prior to birth and / or initiating proceedings at birth.

Completing the pre-birth assessment at an early stage within the pregnancy, i.e. by the 24th week, provides an opportunity for the prospective parents to address any concerns identified and for the multi-agency team to review progress with the implementation of a protection plan prior to the birth of the baby.

A pre-birth conference should be held in the circumstances listed below unless the pre-birth assessment has concluded that the risk no longer applies:

• A pre-birth assessment gives rise to concerns that an unborn child may have suffered, or is likely to suffer, significant harm;
• A previous child has died or been removed from parent/s as a result of significant harm;
• A child is to be born into a family or household that already has children who are subject of a child protection plan;
• An adult or child who is a risk to children resides in the household or is known to be a regular visitor.

Other risk factors which must be considered are:

• The impact of parental risk factors such as mental ill health, learning disabilities, substance misuse and domestic abuse. See Safeguarding Practice Guidance for Guidance.
• A mother under 18 years of age about whom there are concerns regarding her ability to self-care and / or to care for the child.

See Pre-Birth Child Protection Conferences Procedure.

Where the assessment recommends that legal action should be considered, a legal planning meeting should be held as soon as possible to consider initiating action under the Public Law Outline and / or initiating proceedings at birth. This will:

• Avoid additional stress for the pregnant woman in the later stages of pregnancy;
• Provide an opportunity for the prospective parent(s) to obtain legal advice;
• Provide an opportunity to work with the family to explore what support they will be able to give;
• Provide an opportunity to commission specialist assessments; and
• If appropriate, to avoid the need for legal proceedings.

The Public Law Working Party (March 2021) has published “Recommendations to achieve best practice in the child protection and family justice systems”. This provides guidance on best practice in decision making at legal planning meetings, support for families prior to court proceedings and when making an application to a court in care proceedings. The report also recommends that:

• Local authorities and NHS Trusts providing maternity services develop protocols setting out the arrangements for the birth at hospital and an agreed period for the baby to remain in hospital to allow an application to be made to court in a timely way; and
• Local authorities and their family justice board agree protocols providing clarity of expectation and principles under the pre-proceedings phase of the Public Law Outline.

Consideration should always be given to the need for a birth planning meeting. The purpose of the birth planning meeting is for professionals and parents to be clear about their roles and responsibilities and to agree a multi-agency plan to safeguard the baby once born. This plan should be shared with the parents. The social worker with case responsibility will attend this meeting which may be combined with a core group meeting or child in need meeting. The meeting should be held before 34 weeks of pregnancy, or earlier if there is a risk of premature birth. The meeting should consider:

• Any medical/pregnancy related health issues for either mother or baby and the impact this might have on the early postnatal period;
• The arrangements for the immediate protection of the baby if it is considered that there are serious risks posed from parental alcohol consumption, substance misuse; mental ill health and / or domestic violence or another significant safeguarding concern Consideration should be given to the use of hospital security and involving the police1 so that the baby can be police protected;
• Consideration to the safety of baby in mothers care whilst in hospital; is constant supervision required? If so, who should provide this?
• The risk of potential abduction of the baby from the hospital particularly where it is planned to remove the baby at birth;
• The plan for contact between mother, father, extended family and the baby whilst in hospital. Consideration to be given to the supervision of contact – for example whether contact supervisors need to be employed;
• How the mother intends to feed the baby;
• Record the need for a discharge planning meeting to take place prior to discharge;
• Consideration should be given to whether or not alerts should be circulated to other maternity units (locally, regionally or nationally) and to the ambulance service;
• Contingency plans should also be in place in the event of a sudden change in circumstances;
• Who to contact should the baby be born out of hours.

[1] The police do not normally attend birth planning meetings. The plan agreed at the meeting should be shared with the police by the local authority in order that they can update their records.

The hospital midwives should inform children’s social care of the birth of the baby as soon as possible (ideally the allocated social worker will be informed once the expectant mother is admitted in established labour).

• It is expected that there is regular liaison between social care and the maternity unit whilst the mother and baby are in hospital;
• Ward staff should keep a record of any concerns that emerge whilst on the ward. This could be important information for child protection planning or evidence needed for care proceedings;
• If the baby is the subject of a child protection plan, consideration should be given to convening a core group / pre-discharge planning meeting to draw up a detailed plan prior to the baby’s discharge home. (See Child Protection Conferences Procedure). The police should also be informed so that their records can be updated – a PNC record created and flagged as a child subject to a child protection plan;
• It is expected that, where a decision has been made to initiate care proceedings following birth, all necessary paperwork is prepared in advance of the birth to prevent any delay. The social worker must keep relevant maternity staff updated about the timing of any application to the Courts. The lead named midwife for safeguarding/ maternity safeguarding team should be informed immediately of the outcome of any application and placement for the baby. A copy of any orders obtained should be forwarded immediately to the hospital and to the police;
• PLEASE NOTE: The application to court can only be made once the baby is born and is likely to take a few days before the case is heard. If there are immediate child protection concerns prior to the order being granted, then contact the police.

Careful consideration should be given to the need to complete a pre-birth assessment in relation to the pregnancies of looked after children and care leavers. It should not be an automatic decision unless the thresholds are met as outlined above. The rationale for that decision should be recorded. Consideration should also be given to who should undertake the pre-birth assessment:

• For a looked after child, the assessment should not be undertaken by their allocated social worker; the risk to the un-born child should be assessed separately from the best interests of the looked after child;
• For a care leaver, the assessment should never be undertaken by their allocated personal advisor [1];
• If the looked after child or care leaver is placed outside of the LA with statutory responsibility for them, then the pre-birth assessment should be undertaken by the LA in whose area they are residing. The LA with statutory responsibility for the care leaver, should attend all conference and planning meetings and take the lead in ensuring the needs of the care leaver are planned for and met.

[1] The role of the personal advisor in children’s social care is not always properly understood. Personal advisors play an important role in supporting care leavers and their ability to form helpful relationships is well evidenced. Assumptions should not be made about their role in identifying the potential risk to babies; there can be a tendency for other professionals to attribute a greater degree of responsibility for this to personal advisors than should be the case.

Where an expectant mother moves between local authority areas, it is particularly important that the pre-birth assessment is undertaken in a consistent manner.

• The authority in whose area the pregnant woman is residing at the time that the concern is first identified should retain case responsibility until the assessment is complete.
• Where a pregnant woman presents at a hospital without having previously booked at that hospital and / or having not previously received anti-natal elsewhere, then the local authority responsible for the area in which the hospital is located will be responsible for the risk assessment.
• If a pregnant woman is homeless, then the responsibility for undertaking the pre-birth assessment will be with the authority in who's area the concern is first identified, usually through registering for antenatal care.
• If a concern is identified in respect of a pregnant woman who is in prison, then the responsibility for the pre-birth assessment lies with the local authority where the prison is located rather than the local authority in which the woman lived prior to her imprisonment [1].

See also Children and Families Moving Across Local Authority Boundaries Procedure.

[1] See Section 76, Care Act 2014