SCOPE OF THIS CHAPTER
Please note that providers of health services, in particular those providing midwifery services, may have their own detailed agency specific guidance which should be read in conjunction with this guidance.
In June 2022 a link was made to Pre-Birth Flowchart.
Young babies are particularly vulnerable to abuse, and early assessment, intervention and support work carried out during the antenatal period can help minimise any potential risk of harm. This procedure sets out how to respond to concerns for unborn babies, with an emphasis on clear and regular communication between professionals working with the woman, the father / partner and the family.
All professionals have a role in identifying and assessing families in need of additional support or where there are safeguarding concerns. In the vast majority of situations during a pregnancy, there will be no safeguarding concerns.
However, in some cases it will be clear that a co-ordinated response by agencies will be required to ensure that the appropriate support is in place during the pregnancy to best protect the baby before and following birth.
The antenatal period provides a window of opportunity for practitioners and families to work together to:
- Form relationships with a focus on the unborn baby;
- Identify risks and vulnerabilities at the earliest stage;
- Understand the impact of risk to the unborn baby when planning for their future;
- Explore and agree safety planning options;
- Assess the family's ability to adequately parent and protect the unborn baby and the baby once born;
- Identify if any assessments or referrals are required before birth; for example the use of an Early Help assessment;
- Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s);
- Plan on-going interventions and support required for the child and parent(s);
- Avoid delay for the child where a legal process is likely to be needed such as Pre-proceedings, Care or Supervision Proceedings, Section 31 Children and Young Persons Act 2001 in line with the Public Law.
Where professionals become aware that a woman is pregnant, at whatever stage of the pregnancy, and they have concerns for the woman or unborn baby's welfare, or that of siblings, they should not assume that Midwifery or other Health services are aware of the pregnancy or the concerns held.
Whenever additional needs emerge and where targeted support is needed to prevent a deficit in parenting, a range of early help services may be required, coordinated through an early help assessment. This should be contributed to by all relevant professionals and coordinated by the (CWAN) Coordinator. The plan of support should identify what help is required to prevent needs escalating to a point where Statutory Intervention is required under the Children and Young Persons Act 2001.
It should be noted for an early help assessment to be effective the assessment should only be undertaken with the participation of parents. If parents don’t consent to the assessment, then a judgement should be made as to whether the new born baby will be safe in the care of their parents and whether good enough parenting can be provided without the help and support of services.
Whenever concerns arise each professional should follow their agency's child protection procedures and discuss concerns with their safeguarding lead/named/designated professional for safeguarding.
If there are sufficient concerns to consider making a referral to the Initial Response Team, Children and Families, rather than completing an early help assessment and support through EHAS, parental consent should be sought or at the very least the parent should be advised that a referral is being made. Wherever concerns indicate significant harm then a referral must be made. The two principle documents determining whether Section 46 NARRATES should be undertaken are:
- The Children and Young Person’s Act;
- The Isle of Man Integrated Continuum of Needs document.
Where more complex needs emerge and whenever a child is in need of safety and protection then the NARRATES (S46) single assessment framework for assessment must be undertaken as part of the Section 46 enquiries whilst analysing the risk using the Dynamic Risk Analysis tool (DRAT).
Risk factors which could indicate that an unborn child may be likely to suffer significant harm and therefore be subject to a NARRATES (S46) assessment may include:
- Involvement in risk activities such as substance misuse, including drugs and alcohol;
- Perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
- Victims or perpetrators of domestic abuse;
- Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children;
- A history of violent behaviours;
- May not be able to meet the unborn baby's needs e.g. significant learning difficulties and in some circumstances severe physical or mental disability;
- Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care;
- Currently 'Looked After' themselves or were looked after as a child or young person (care leavers);
- Adverse Childhood Experiences (ACEs);
- Are teenage/young parents and are vulnerable;
- Recent family break up and social isolation/lack of social support;
- Any other circumstances or issues that give rise to concern.
The list is not exhaustive and, if there are a number of risk factors present, then the cumulative impact may well mean an increased risk of significant harm to the child. If in doubt, professionals should seek advice about making a referral.
3. Working with Fathers / Partners
Fathers play an important role during pregnancy and afterwards.
Involvement of prospective and new fathers in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father is resident or not. Pregnancy and birth are the first major opportunities to engage fathers in appropriate care and upbringing of children.
It is important that all agencies involved in pre and post-birth assessment and support, fully consider the significant role of fathers and wider family members in the care of the baby even if the parents are not living together and, where possible, involve them in the assessment. This should include the father's attitude towards the pregnancy, the mother and new-born child and his thoughts, feelings and expectations about becoming a parent.
Information should also be gathered about fathers and partners who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified. A careful assessment of the role that the person has in relation to the woman and any other children in the household as well as their views about the future care of the baby should be undertaken.
A failure to do so may mean that practitioners are not able to accurately assess what mothers and other family members might be saying about the father's role, the contribution which they may make to the care of the baby and support of the mother, or the risks which they might present to them. Background police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.
Involving fathers in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered.
4. Protection and Action to be Taken
Where any professional is concerned that an unborn child or other children in the family may be likely to suffer significant harm, they should seek advice from their agency Safeguarding Lead without delay. The Safeguarding Lead will consider with them whether to refer to the Initial Response Team, Children and Families Division - see Referrals Procedure in accordance with ‘the duty to safeguard’ established in the safeguarding Act 2018.
The threshold criteria for a Section 46 may be identified at the point of the referral, during multi-agency checks, within the Strategy Discussion or during the course of the NARRATES (S 46).
Once a referral has been made and accepted a Strategy discussion should be convened. It is during that discussion that arrangements should be made to carry out the Section 46 NARRATES as a part of the enquiries.
The legislative requirements of the Safeguarding Act 2018 determine that each agency has a duty to cooperate, assist and provide information in support of Child Protection Enquiries.
All agencies should be involved in the development of a NARRATES assessment with a clear focus on the child's needs to enable conclusions/recommendations to be made to inform the next steps.
A pre-birth conference (see Child Protection Conferences Procedure) may be required if the outcome of the NARRATES concludes that the child is likely to suffer significant harm.
A pre-birth conference should share all the relevant information and develop a Child Protection Plan if required. The timing of the conference should take into account the expected date of delivery and ideally take place by 24 weeks gestation of the pregnancy, or earlier if there is a history of premature birth.
If a decision is made that the unborn child will be made the subject of a Child Protection Plan, a Core Group should be established at the Initial Child Protection Conference. The Core group should meet prior to the birth within the locally stipulated days from the Conference date and certainly prior to the baby's return home from hospital.
There should be no delay in making the referral for the unborn baby. The referral can be made at 16 weeks gestation, this will allow time for all necessary checks to be made before any further steps are taken. Timescales are crucial in order to avoid any undue delay when making plans and agreeing plans for the pre-birth planning meeting and other meetings agreed. Particularly if it becomes evident that urgent action is required, such as removal of the child at birth.
Decision to Remove at Birth
If the NARRATES concludes that the child should be removed at birth, the Children and Families Division should seek legal advice about an application for an Interim Care Order. The application to the court can only be made once the child is born but there should be no delay in seeking the order. A Pre-Birth Planning Meeting should be arranged.
The Assessment should be shared, when completed, with the parents and, if instructed, to their Advocate to give them opportunity to challenge the proposed Care Plan and assessment.
The circumstances of the woman and other relevant adults should be reviewed regularly to allow for ongoing assessment of need and risk and consider any action required to safeguard the child. The Assessment should be updated to take into account relevant events pre-and post-delivery where these events could affect an initial conclusion in respect of risk and care planning of the child.
5. Pre-birth Planning Meeting
A Pre-Birth Planning Meeting should be arranged following the outcome of the decision to remove the child. The meeting should agree a detailed plan to safeguard the baby around the time of birth which should include:
- How long the baby will stay in hospital (for babies born to substance using mothers there needs to be a period of time to monitor for withdrawal symptoms);
- How long the woman will remain on the ward;
- Any risks to the baby in relation to breastfeeding e.g. HIV status of the woman;
- The arrangements for the immediate protection of the baby if the risk assessment has highlighted serious risks to the child e.g. from parental substance misuse, mental health concerns, domestic abuse. This should also include contacting the police or the use of hospital security;
- The risk that the parents might seek to remove the baby from the hospital especially if the plan is to remove the baby at birth;
- The plan for managing contact with the baby by the mother, father or an extended family and who will supervise the contact;
- The plan for the baby upon discharge, and what visits will be made upon discharge and by whom;
- Contingency plans should be in place in the event of a sudden change in circumstances. These should include instructions for hospital staff if the birth happens over the weekend or a Bank Holiday. It should be clear who to contact if the birth takes place after hours. The Children and Families duty worker should also be notified of the pre-birth plans for the baby.
All agencies attending the meeting should receive a copy of the plan as well as other relevant agencies for example the parents' GPs. The Lead Midwife should inform midwifery staff of the details of the plan.
A detailed pre-birth NARRATES can provide an early opportunity to develop a good working relationship with parents during the pregnancy, especially where there are concerns. It can mean that vulnerable parents can be offered support early on, allowing them the best opportunity to parent their child safely and effectively. Importantly, it helps identify babies who may be likely to suffer significant harm, and can be used to develop plans to safeguard them.
There are some potential issues that can arise. The involvement of the Children and Families Division (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the mother not attending hospital at the time of birth.
It may have an adverse effect on the parents' mental or physical health or heighten the risks that had raised the concerns in the first place. The fear of losing the baby may undermine the attachment and bonding process between the parent and child. There is a danger that the woman may end up harming herself or her unborn baby or seeking to terminate her pregnancy.
It is vital that there is good communication with the pregnant woman, the birth father and, if different, her current partner in order to reduce the chance of such issues arising.
Professional Operational NARRATES Guidance (2016)