This update section is based on the Report of the Caleb Ness Inquiry, chaired by Susan O'Brien Queen's Counsel (QC). This document is in the public domain and, to aid widespread access, a copy of the report has been included here (650Kb PDF file).

On 18th October 2001 Caleb Ness - an 11-week-old baby - was admitted to the Royal Hospital for Sick Children in Edinburgh (RHSC). He was found to be dead on admission. As the Report of the Inquiry into his death shows, Baby Caleb's short life had been very stormy.

Baby Caleb was born to a mother who had been a drug addict for twenty-years. She had made several unsuccessful attempts to overcome the addiction but was using methadone by prescription throughout the pregnancy. As well as being a drug addict, the report makes it clear that she had "a long history of prostitution" and "many criminal convictions". She had two other children, both of whom had been taken into care. She was known to have been suffering post- natal depression.

His father was also known to have been associated with drugs, having been released from prison on license for drug-related offences in late summer 2000. Prior to that Caleb's father has also been convicted for the serious assault of an adult. In between meeting Caleb's mother in the autumn of 2000 and Caleb's death in 2001, he had suffered a brain injury. At the time of the death, his brain injury made him confused and he was depressed.

Caleb was born with neonatal abstinence syndrome. This is one of the possible consequences of drug misuse during pregnancy which were described in chapter four. Neonatal abstinence syndrome happens when a newborn baby is withdrawing from the effects caused by the mother's drug misuse. Immediately after his birth on 30th July 2001, Caleb was admitted to the special care baby unit at the Royal Infirmary of Edinburgh at Little France (RIE). He was there for three weeks before being discharged into the care of his mother.

The findings from his post-mortem showed that in the seven weeks between coming home from the RIE and his death in the RHSC, Caleb had suffered from at least three separate episodes of trauma to the chest, probably caused by gripping during shaking. The findings also suggested that Caleb died rapidly from a brain haemorrhage following traumatic injury, probably caused by rough shaking.

In February 2003, Caleb's father was convicted of culpable homicide on the grounds of diminished responsibility caused by his brain injury.

After the conclusion of the court case, the Lothian Area Child Protection Committee commissioned an Inquiry into the death of Caleb Ness. An independent QC chaired this Inquiry with support from both a Community Paediatrician not involved in the case and an external Social Worker, both of whom had experience of child protection. The findings of this Inquiry were made public in October 2003. The Inquiry concluded that:

"No single individual should be held responsible. We identified fault at almost every level in every agency involved. Many concerned professionals did their best for this family, but too many operated from within a narrow perspective without full appreciation of the wider picture."

The executive summary of the report details a series of factors that the Inquiry team concluded had contributed to the baby's death. These may be summarised as:

• A failure to take into account all the relevant information which would have helped professionals make a full assessment of the risk to Caleb, especially where there were factors which were the consequence of the health status of his parents;
• A flawed child protection case conference process and ongoing problems with information sharing which meant that Caleb continued to be at risk, even through he had been placed on the Child Protection register;
• Differences of understanding about what constituted appropriate monitoring of baby Caleb and failures by some individuals to respond appropriately when the monitoring that did occur suggested he was at increased risk;
• A lack of senior social work involvement in the assessment of risk, in the re-assessment of risk, in decision making and in ongoing supervision;
• An absence of clear management responsibility and accountability for child protection within health agencies and;
• A failure to understand the roles and responsibilities of others with regard to child protection. Amongst the services focussing on children, this took the form of professionals making too many assumptions of what others would be doing. On the part of the services associated with Caleb's parents, the failure was more associated with a lack of understanding that they had a responsibility for child protection. The need for improved training for professionals was identified.

The Inquiry team made 35 recommendations for improving child protection processes. Of these, 11 are specifically directed towards the NHS in Lothian with a further 13 requiring NHS Lothian involvement. These are detailed on the following pages (see Box U1).

In collaboration with our Local Authority partners, NHS Lothian is committed to creating a joint action plan that will respond positively to each and every one of the recommendations in the Inquiry report. It has established a Child Protection Action Group, chaired by the Child Health Commissioner Margaret Wells, to develop appropriate actions to include in the joint action plan. Amongst the work already put in hand has been:

1. Increasing awareness amongst NHS Lothian about their responsibilities for child protection. This took the form of both an electronic briefing to staff and a simple reminder card included in the November salary advice (see Box U2);
2. Undertaking an audit of all Lothian children who are on the Child Protection Register to ensure that they are not at risk from factors identified by the Inquiry team as being at fault;
3. Bringing forward the timetable for implementing the existing NHS Lothian child protection training programme and requesting the Lothian Area Child Protection Committee health sub-group to bring forward proposals for extending and enhancing the training programme across all staff groups at all levels within NHS Lothian;
4. Creating a working party to develop protocols for sharing information concerning risks to newborn children identified by obstetric and neonatal NHS staff. This will include the creation of a lead consultant for child protection within neonatal medicine.; and
5. Creating a working party to develop protocols associated with the identification and appropriate communication of risk to children arising from vulnerable parents/carers who are known to adult services. In the first instant this will focus on people with acquired brain injury, though it is recognised that this should be a model which can be used with other client groups.

The work needed to address all of the recommendations will be identified in the final version of the joint action plan.

No.	Section	Recommendation
1	3.4.1	RECOMMEND that the CPCC minute format is changed, so that the Chairperson has an opportunity and obligation to sign the Minutes.
2	3.6.2	RECOMMEND that an explicit discussion and decision as to whether or not the child should be discharged to the care of the parent should always be part of a CPCC for a newborn baby.
3	4.2.9	RECOMMEND that a Joint Working Party prepares a Joint Protocol to inform the treatment and care of babies born with neonatal abstinence syndrome.
4	4.2.9	RECOMMEND automatic referral to the Social Work Department of any baby born with neonatal abstinence syndrome, who has not been identified pre-birth.
5	4.3.3	RECOMMENDATION that the Trust organises and funds mandatory child protection training, as identified by their own specialist.
6	4.4.6	RECOMMEND that the Trust carefully reviews its record keeping systems to facilitate effective sharing of information.
7	4.4.8	RECOMMEND that Lothian Primary Care Trust urgently allocates resources and skilled staff to institute mandatory child protection training for staff at all levels, which must include advice on the extent to which a patient's right to medical confidentiality can be breached when a child is at risk.
8	4.5.2	RECOMMEND that the pro forma invitation issued by Social Work Departments throughout the City should be reviewed, in consultation with the Police, and a new pro forma drawn up, which offers the Police far more information.
9	4.5.20	RECOMMEND that the Police review the detail of their approach to physical and sexual abuse in collaboration with Child Protection specialists from outside the Police. Thereafter, we recommend that they re-examine their internal procedures for allocating cases.
10	4.5.21	RECOMMEND that a clear understanding is reached between the Police and the Social Workers on information sharing prior to the CPCC.
11	5.7.6	RECOMMEND that the Social Work Department refrains from interviewing witnesses where an inquiry has been set up.
12	8.7	RECOMMEND that the Housing Department of the City of Edinburgh reviews what happened here, with a view to streamlining and supporting applications by people suffering from brain injury.
13	8.8	RECOMMEND that Lothian Primary Care Trust facilitates the registration with GPs of brain injury patients, with a view to providing them with appropriate care outside the hospital.
14	9.1.4	RECOMMEND that the section of the Child Protection Guidelines is amended to reflect the expectation that health care professionals will notify the social work department if they anticipate there may be risk after birth for a child still in utero, even if it means breaching the duty of confidentiality owed to either mother or father.
15	9.1.6	RECOMMEND that a file entry is made when information is shared in this way, and in particular when liaison workers pass that information out beyond the hospital.
16	9.1.7	RECOMMEND that the LUH Trust reviews the accuracy of its record keeping for at risk children.
17	9.1.10	RECOMMEND that serious dialogue is undertaken to clarify the role of the Trusts' Child Protection Services within an interagency context.
18	9.1.12	RECOMMEND that Lothian Health ensures that its various Trusts fund the training requirements identified by their own senior staff with management responsibility for Child Protection.
19	9.1.15	RECOMMEND that the best means of triggering early reviews or immediate action in response to health visitors' concerns be investigated, and improved upon, as a matter of urgency.
20	9.1.17	RECOMMEND that steps are taken to clarify when medical duties of confidentiality towards a patient who is caring for a child can be waived.
21	9.1.24	RECOMMEND that Children and Families and Criminal Justice social work services review their joint working practices in this area as a matter of urgency.
22	9.2.2	RECOMMEND that a checklist of invitees for CPCCs is compiled as an aid for social workers in the future.
23	9.2.6	RECOMMEND that all agencies make it a priority to collaborate and put in place effective risk assessment processes to underpin decision making.
24	9.2.7	RECOMMEND that the use of Senior Practitioners as Chairpersons of Case Conferences is discontinued.
25	9.2.8	RECOMMEND that formal training in how to chair a CPCC is introduced for all new Chairpersons.
26	9.2.9	RECOMMEND that the CDPS provides information for the use of CPCCs about the inferences which can be drawn from the factual information they are providing.
27	9.2.10	RECOMMEND that Social Workers involved with CPCCs in Lothian are encouraged to refer to the Reporter, where there is a history of previous children who have been taken into care, unless the circumstances are exceptional.
28	9.2.10	RECOMMEND that CPCC Chairs, in discussion with the Reporter, agree appropriate referral criteria.
29	9.3.1	RECOMMEND that resources are allocated for the employmentand training of administrative staff to take and type up Minutes relating to CPCCs.
30	9.3.2	RECOMMEND that the pro forma Minutes are changed slightly, to include a section for signature by the Chair of the relevant CPCC.
31	9.3.6	RECOMMEND that the supervising Senior Social Worker should attend Child Protection Case Conferences, along with the case worker from the Children and Families Team.
32	9.3.15	RECOMMEND that consideration should be given to this model of a "core group", as a means of developing and implementing the Child Protection plan.
33	9.3.16	RECOMMEND that senior managers with responsibility for child protection practice have appropriate training to discharge that responsibility, in every agency.
34	9.3.17	RECOMMEND that the Chief Executives and Medical Directors give urgent consideration to lines of accountability.
35	9.3.18	RECOMMEND that an independent audit of Child Protection cases is carried out.

Some recommendations appear more than once.
More than one agency: 1, 2, 3, 4, 8, 10, 14, 17, 18, 19, 20, 23, 30, 32, 33, 35.
Mostly Social Work: 21, 22, 24, 25, 27, 28, 29, 31.
Mostly Lothian Primary Care NHS Trust: 7, 13, 18, 26, 34.
Mostly Lothian University Hospitals NHS Trust: 5, 6, 15, 16, 18, 34.
Mostly Police: 8, 9, 10.
Housing: 12.