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4.13 Unborn Babies at Risk of Significant Harm

SCOPE OF THIS CHAPTER

This section sets out -

  • The circumstances in which a pre-birth Child Protection Conference should be arranged;
  • Specific issues to be considered in arranging a pre-birth conference;
  • Issues to be considered in relation to concealment and denial of pregnancy;
  • Issues to be considered in relation to removal of a child at birth or on discharge from hospital; and
  • Specific risks identified in Serious Case Reviews.

This chapter was added to the manual in January 2014.


Contents

  1. Referral
  2. Pre-Birth Child Protection Conference
  3. The Child Protection Plan
  4. Concealment and Denial of Pregnancy
  5. Legal Issues and Removal at Birth or on Discharge
  6. Actual or Attempted Removal of a Baby from Hospital, Contrary to the Child Protection Plan

    Appendix 1: Unborn Baby at Risk of Significant Harm Flowchart

    Appendix 2: Hospital Birth Plan


1. Referral

1.1 Whenever any agency or practitioner has concerns about the welfare of an unborn baby they should make a referral to children’s social care as indicated in the Making Referrals to Children's Social Care Procedure. This referral should normally be made at 20 weeks into the pregnancy to enable the necessary information sharing to take place before the birth.
1.2 If concerns arise earlier than 20 weeks into the pregnancy the practitioner should consult the agency safeguarding lead about the possible need to refer the matter to children’s social care. If a referral seems appropriate the practitioner should consider an assessment under the Common Assessment Framework (CAF) in preparation for this.
1.3 In some cases concerns will only become clear later than 20 weeks into the pregnancy.  In this situation an immediate referral should be made to children’s social care and, depending on the circumstances, they may follow the procedure set out below without meeting the deadlines, or may arrange a Strategy Discussion.
1.4 When a referral is made at 20 weeks into the pregnancy, children’s social care will carry out an assessment - this must involve the midwifery service, who can advise on consultation with other medical and nursing staff such as the GP. The assessment should be completed by 30 weeks into the pregnancy.
1.5 The mother’s normal address and the likely place of birth of the baby should be established in order to identify the responsible professionals and avoid delay in planning and management. It is particularly important to identify cases in which the mother does not have a permanent address (for example staying with a friend/boyfriend or in a hostel) so that responsibility can be assigned.
1.6 The name of the father, and the mother’s partner if different, should be established and this name should also be used in any correspondence and referrals between agencies. However, the mother’s name must be the primary name used for the unborn child.
1.7 It is important to try to obtain the cooperation of the parents in planning at every stage. Practitioners must acknowledge that the welfare of the unborn baby cannot be ensured without the engagement of the mother.
1.8 Following the assessment, children’s social care will make a decision about whether to convene a pre-birth Child Protection Conference in accordance with Legal Issues and Removal at Birth or on Discharge of these procedures. The basis of this decision is whether it appears that at birth the child will be at risk of Significant Harm.


2. Pre-Birth Child Protection Conference

2.1 If the Social Work Assessment concludes that the child is likely to be at risk of Significant Harm, children’s social care should arrange a pre-birth Child Protection Conference by 30 weeks into the pregnancy or within 15 days of a late notification. This will have the same status, and will proceed in the same way, as other Initial Child Protection Conferences.
2.2 All those who would normally be invited to attend an initial Child Protection Conference will be invited to the pre-birth conference. The involvement of the Health Visiting Service and the Midwifery Service is essential - both the community midwife and the named midwife from the maternity unit. The child's parents should be invited and should be fully involved in planning for their child's future unless there is evidence that to do so would place the child at increased risk of Significant Harm. It may be appropriate to invite other family members, where it is likely that they will have a significant support role to mother and/or baby following the birth.
2.3 The pre-birth conference should identify the actions needed to safeguard the unborn child, including actions to be taken if the mother leaves the area, presents at a different hospital, or breaks contact with professionals.
2.4 Any plan devised to promote the unborn child’s safety should specifically include a contingency plan to respond if the child is born before the expected date of delivery.
2.5 If the conference concludes that the child needs a protection plan, the Core Group must include future Health Visitor.
2.6 If the Child Protection Plan recommends that the child should be removed from the mother, see Legal Issues and Removal at Birth or on Discharge.
2.7 A pre-birth Child Protection Conference may be part of, or held in conjunction with, a review conference in respect of one or more children of the same household and/or family who are the subjects of Child Protection Plans.
2.8 A review of the Child Protection Plan must be arranged no later than 3 months after the pre-birth Child Protection Conference, but it may be arranged earlier if it is necessary to update the Child Protection Plan before or after the birth.

 

Child born before conference

2.9

If the child is born before the date set for the pre-birth conference -

  • The midwife will notify the health visitor and children’s social care, who will arrange an urgent Strategy Discussion;
  • The Strategy Discussion should specifically agree the arrangements for care of the child, and for any intervention pending the initial Child Protection Conference; and
  • The child should not be discharged from hospital until after the Strategy Discussion.

 

If mother goes missing

2.10 If the mother goes missing before the birth, and the unborn child is subject to a Child Protection Plan, the Child Protection Conference must be reconvened to make any necessary amendments to the Child Protection Plan, including a plan to locate the mother (see Child Protection Review Conferences Procedure). If the unborn child is not subject to a Child Protection Plan, a Section 47 Enquiry should be initiated.


3. The Child Protection Plan

3.1

The Child Protection Plan must address:

  • The welfare of the unborn baby;

    This must include any factors likely to harm the unborn child, such as substance misuse, or domestic violence;
  • Plans for assessment and intervention after the birth; and
  • Ensuring that the Midwifery Service passes all relevant information to the Health Visitor on transfer of responsibility for the baby's care.
3.2 An unborn child who is in need of a Child Protection Plan will also need a hospital birth plan to ensure that all health professionals who come into contact with the new born child are aware of the child protection concerns and know what protective measures are required. The midwife will draw up the birth plan in consultation with children’s social care - the framework for the birth plan is appended to this Section at Appendix 2: Hospital Birth Plan. A copy of the birth plan must be filed in the child’s records.
3.3 The Core Group must meet within 10 working days of the decision that the child needs to be the subject of a Child Protection Plan and again within 10 working days after the birth.
3.4 At 36 weeks into the pregnancy the Core Group will meet to ensure that all practitioners understand their responsibilities under the Child Protection Plan and hospital birth plan.


4. Concealment and Denial of Pregnancy

 

This policy and procedure is for anyone who may encounter a woman who conceals the fact that they are pregnant or where a professional has a suspicion that a pregnancy is being concealed or denied. This policy and procedure should be read in conjunction with the rest of these LSCP procedures for safeguarding children.

The concealment and denial of pregnancy will present a significant challenge to professionals in safeguarding the welfare and well-being of the foetus (unborn child) and the mother. While concealment and denial, by their very nature, limit the scope of professional help better outcomes can be achieved by co-ordinating an effective inter-agency approach. This approach begins when a concealment or denial of pregnancy is suspected or in some cases when the fact of the pregnancy (or birth) has been established. This will also apply to future pregnancies where it is known or suspected that a previous pregnancy was concealed.

 

Definitions

4.1

A concealed pregnancy occurs when:

  • A woman knows she is pregnant but does not tell any health professional; or
  • A woman tells a professional she is pregnant but conceals the fact that she is not accessing antenatal care; or
  • A woman tells one or more other persons that she is pregnant but she conceals the fact from all health agencies.
4.2

A denied pregnancy occurs when a woman is unaware of, or unable to accept, the existence of her pregnancy -

  • Physical changes to the body may not be present or may be misconstrued;
  • The woman may be intellectually aware of the pregnancy but continue to think, feel and behave as though she were not pregnant;
  • The woman may refuse to acknowledge the pregnancy because she fears the consequences if it becomes known in her family or community; or
  • In some cases a woman may deny her pregnancy because of mental illness, substance misuse or a history of loss of a child or children.

 

Risks of a concealed or denied pregnancy

4.3

The possible implications of concealment and denial of pregnancy are wide-ranging -

  • If the woman has concealed the pregnancy because of fear of the reaction of family members or members of the community, these fears may be well founded;
  • Concealment of a pregnancy may indicate that the woman has immature coping styles or is unprepared for the challenge of looking after a new baby;
  • Inappropriate medical advice may be given to the woman and any underlying medical conditions and obstetric problems will not be revealed if antenatal care is not sought;

    For example a medical practitioner unaware of the pregnancy may prescribe potentially harmful medication;
  • Potential risks to the mother and child may not be detected due to lack of antenatal care in utero as well as subsequently;

    Where concealment is a result of substance misuse there can be significant risks for the child’s health and development;
  • In a case of denied pregnancy the effects of going into labour and giving birth can be traumatic;
  • An unassisted delivery can be very dangerous for both mother and baby, due to complications during labour and delivery;
  • The mother may lack an emotional bond with the child following birth, or be unwilling or unable to consider the baby’s health needs.

 

Particular issues if the woman is under 18

4.4

Particular issues arise when a young woman under the age of 18 is believed to be concealing a pregnancy -

  • If the young woman is aged under 16 there may be a need to investigate a criminal offence; and if the young person is aged under 13 then a referral must be made to Children’s Social Care and the Police;
  • The young woman herself may be a Child in Need;

    If this appears to be the case a referral should be made to children’s social care - whether or not the pregnancy has been confirmed;
  • The young woman may be at risk of Significant Harm;

    The source of the risk could be the father of the child, or the mother’s family or community, or the mother may pose a risk to herself. Any concerns about the mother’s welfare and safety should be referred to children’s social care under these procedures;
  • Practitioners will need to respond to the mother’s needs as a child and to her wishes as mother of the unborn baby, but there will be times when the needs of the unborn baby must take priority over the mother’s needs and wishes.

 

Action when a concealed or denied pregnancy is suspected

4.5 A practitioner who suspects that a pregnancy is being concealed or denied should strongly encourage the woman to go to her GP to access ante-natal care. The practitioner should make every effort to encourage the woman to obtain medical advice. If this is unsuccessful it may be appropriate to consult the Designated Person for Child Protection.
4.6

Where any practitioner has a strong professional concern or suspicion about the possible concealment or denial of a pregnancy they should:

  • Consult other agencies known to have involvement with the woman so that a fuller assessment of the available information and observations can be made;

    In these circumstances the welfare of the unborn child will override the mother’s right to confidentiality;

    And
  • Make a referral to children’s social care about the unborn child - and about the mother if she is under 18;

    As with any referral to children’s social care the woman should be informed about this unless there is a genuine concern that this may cause her to attempt to harm herself or the unborn baby;

    In making the referral the practitioner should draw attention to any concerns about the family background or home circumstances.

 

Action when a concealed or denied pregnancy is revealed

4.7 A pregnancy is revealed when the woman discloses the pregnancy to a professional or goes into labour.  At this point it is vital that all information about the concealment or denial is recorded and shared with relevant agencies to ensure the significance is not lost and risks can be fully assessed and managed.
4.8

The circumstances of each case must be explored and appropriate support and guidance offered to the woman -

  • When a concealed or denied pregnancy is disclosed to a professional they must refer the unborn child to children’s social care who will consider the need to initiate a Section 47 Child Protection enquiry and complete a pre-birth assessment. Based on the outcome of any Section 47 Enquiry, an Initial Child Protection Conference may be convened to consider the safety of the unborn child, and the mother if she is under 18;
  • When a pregnancy is concealed or denied to birth the midwife must make an urgent referral to children’s social care agencies;

    The baby should not be discharged until a Multi-Agency Strategy Meeting has been held and relevant assessments undertaken;
  • In all circumstances, consideration must be given at the earliest opportunity to a referral to mental health services for an assessment of the mother;
  • The key question to explore as part of the multi-agency assessment is the reason for the concealment or denial of the pregnancy. This information will inform the assessment of the level of risk to the unborn or newborn child as well as the plan to support the needs of the unborn or newborn child and their mother.
Midwives should ensure that information regarding the concealed pregnancy is placed on both the child’s and the mother’s health records. A discharge summary from maternity services to primary care must report if a pregnancy was concealed or denied, or was booked late (beyond 24 weeks).
4.9 If an appointment for antenatal care is made late (beyond 24 weeks) the midwife must consider whether there is cause for concern for the welfare of the unborn baby. If so, she must make a referral to children’s social care. The woman should be informed that the referral is to be made, unless the midwife has significant concerns that this would increase the risk to the woman or the unborn child.
4.10 When a concealed or denied pregnancy has been revealed all practitioners must be alert to the mother’s level of attachment to the child, her acceptance of future contact with health professionals and the response of her partner/family to the situation.

 

Initial action by children’s social care

4.11 Children’s social care will take a referral in which concealed or denied pregnancy is an issue as an expression of concern about the welfare of the unborn child.  In all cases, a Multi-Agency Strategy Meeting will be convened to assess the information and formulate a plan.  A pre-birth Assessment will be undertaken where based on strong professional judgement there is sufficient information and/or evidence to suspect that there is a pregnancy.
4.12 Every effort should be made to resolve the issue of whether the woman is pregnant or not.  She cannot be forced to undergo a pregnancy test or medical examination against her will, but in the event of refusal, social workers should proceed on the assumption that she is pregnant unless it is proved otherwise, and should make plans to safeguard the baby’s welfare at birth.
4.13 If the woman is aged under 18 children’s social care will consider whether she herself may be a Child in Need and whether she appears to be at risk of Significant Harm.  This will require a sensitive and confidential approach at first, until it is clear whether the young woman is willing to make realistic plans for the baby, including informing her parents/carers.  The social worker may need to speak to her without her parent’s/carers’ knowledge in the first instance, particularly if the pregnancy has not yet been confirmed.
4.14 If a young woman under the age of 18 refuses to engage in constructive discussion, and parental involvement is considered necessary to address the risk to mother and child, the social worker will consider whether to inform her parent/carer. In this situation the potential risks to the unborn child and to the health of the mother will normally outweigh the young woman’s right to confidentiality, but before taking this action the social worker must consider the reasons why the young woman is concealing the pregnancy from her family.
4.15 If the woman is aged under 16 there may also be a need to investigate a possible criminal offence and/or to initiate section 47 enquiries in respect of the expectant mother.

 

Concealed birth

4.16 There have been cases in which the mother not only conceals the pregnancy but also the birth.  In these circumstances if the baby dies the body may be concealed.  Concealing a birth (including concealing a still birth) is a criminal offence, but enquiries into the circumstances should be conducted sensitively and with due regard to the context in which the concealment took place.

 

Application of the child protection process

4.17 If a woman arrives at hospital, either following an unassisted birth or in labour following a concealed pregnancy, children’s social care must convene a Strategy Meeting in respect of the child.
4.18 When pregnancy has been confirmed, or consent to a pregnancy test has been refused, children’s social care will convene a Strategy Meeting involving the General Practitioner, midwifery services, the police and other relevant agencies. The Strategy Discussion will assess the information and formulate a plan to carry out a pre-birth assessment and offer the woman appropriate support and guidance.
4.19 The factors considered by the Strategy Discussion will include the need to maintain confidentiality, at least until the pregnancy is confirmed; the age of the woman; the circumstances in which she is living; and whether she appears to be the victim of a criminal offence (for example if she is aged under 16). In all cases in which a child has been abandoned, been harmed or has died the police and children’s social care will initiate Section 47 Enquiries.


5. Legal Issues and Removal at Birth or on Discharge

5.1 If a pre-birth Child Protection Conference decides that there is a need for a Child Protection Plan, it should consider whether there is a need to separate the mother and child and, if so, how this can be achieved.  If the mother can make suitable arrangements for the child’s care it may be possible to avoid the need to remove the child.
5.2

If a pre-birth Child Protection Conference decides that there may be a need to remove the child from the mother, either at birth or on discharge -

  • Lead responsibility for the decision whether to remove a child following birth lies with children’s social care;
  • Children’s social care will make this decision in consultation with other agencies, and this will always include the local authority’s legal department;
  • The conference must ensure that all key staff are clear about the roles of children’s social care, the Police and the Midwifery Service in the removal process; and
  • If the conference recommends removal at birth rather than at discharge, the minutes of the conference must record clearly the reasons why this is felt necessary. 
The action planned must be proportionate to the assessed risk.
5.3

If the Child Protection Plan includes the removal of the child from the mother, it must also state clearly that either:

  • Children’s social care intends to seek an Emergency Protection Order or an Interim Care Order;

    In this case the plan must set out clearly who will be responsible for gathering the evidence and making the application, and the action to be taken to ensure that appropriate action is taken if the child is born at night or during a weekend;

    Or
  • The mother has signed a Section 20 agreement, agreeing for the child to be Accommodated by the local authority.

    In this case explicit, informed consent must be given - see paragraph 5.6.
5.4 If the plan for the child is to initiate legal proceedings, a legal planning meeting will be convened under the Public Law Outline; however, no court order can be made until after the birth.
5.5 Sometimes sharing this plan with a parent would increase the risk to the unborn child.  In this situation a manager in children’s social care may decide that this part of the plan should not be disclosed to the parents.
5.6

A baby can only be removed from its mother in the following circumstances:

  • The mother explicitly, and with full understanding, agrees to that removal and the child is Accommodated under Section 20 of the Children Act 1989;

    Failure to object when the child is removed is not explicit consent - the parent must understand what is planned and that they have the right to refuse to cooperate, and must clearly state that they consent to the planned action.  It is always preferable that consent is given in writing, and all staff should be aware that the parent may withdraw it at any time;

    Or
  • There is a court order authorising removal;

    This may be an Emergency Protection Order or Interim Care Order;

    Or
  • There is a real and immediate risk to the baby of Significant Harm by a parent or carer and removal is necessary to protect the safety of the baby;

    In this case, Police Protection should be considered. This is an interim measure (maximum 72 hours) during which the Police or the local authority will urgently seek a court order.
Any removal of a baby from its mother outside the circumstances set out above is unlawful and is likely to be a breach of Article 8 of the European Convention on Human Rights.
5.7 If the child is to be removed at birth, copies of all documentation supporting this plan must be kept at the hospital.  At the time of the removal, the social worker will provide a copy of the court order or the section 20 agreement (as described in Paragraph 5.3) to be placed in the hospital records and send a copy to the social care Emergency Duty Team.
5.8

If the baby is not to remain in the parents’ care:

  • The social worker must agree a discharge plan with the hospital staff;
  • The local authority must provide a car seat to transport the baby safely;
  • On arrival at the hospital, the social worker must have on their person the appropriate form of identification. 
Midwifery staff will not allow the baby to leave the hospital with anyone who does not carry appropriate identification.
5.9

The social worker must provide the following information to the Hospital staff:

  • Name, address and contact telephone number of the carer to whom the baby is to be discharged;

    Hospital staff must not disclose the baby’s discharge address to the parents and their family: the decision to disclose this address is the responsibility of children’s social care;
  • General Practitioner’s name, address and phone number; and
  • The name, address and contact telephone number of the Health Visitor relevant to the baby’s discharge address.
5.10

Hospital staff will inform the social worker about the Midwifery Service that will be visiting the baby, and about any health issues relating to the baby, including:

  • The baby’s feeding requirements;
  • Birth marks/blemishes identified prior to discharge; and
  • Follow up appointments.


6. Actual or Attempted Removal of a Baby from Hospital, Contrary to the Child Protection Plan

6.1

If there is any attempt by a parent to remove a child contrary to the Child Protection Plan and without the permission of the local authority, in order to minimise the risk of Significant Harm the health professional must contact the police by dialling 999.  The health professional must also contact:

  • Hospital security;
  • Named Nurse/Midwife for Safeguarding Children;
  • The allocated social worker, or the Emergency Duty Team; and
  • The Maternity Directorate Manager, or Head of Midwifery.


Appendices

Appendix 1 sets out in a flowchart the steps required in respect of an unborn baby at risk of Significant Harm.

Click here to view Appendix 1: Unborn Baby at Risk of Significant Harm Flowchart

Click here to view Appendix 2: Hospital Birth Plan

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