Instructions. [This pro forma is designed for social workers to hand complete – the typed pro forma differs slightly in design.]
This form is to be used for all unborn babies who become subject to child protection procedures. This information is required by parents, hospital staff and other relevant agency workers involved in the child protection procedures.
This form is to be completed by the social worker at the end of the conference when recommendations are being listed. The Chairperson will ensure that the conference provides the necessary information.
The completed form should be typed and a copy sent to the Named Midwife for Child Protection, accompanied by the conference recommendations, within 48 hours of the conference. Copies to be given to parents.
BASIC INFORMATION. (This section can be completed prior to the conference)
Mother's name:______
Date of birth:______
Home address:______
Father/partners name:______
Date of birth: ______
Home address:______
Unborn baby's estimated date of delivery (edd):______
Proposed surname of baby:______
Hospital/Midwifery Unit for birth:
Midwife's name:______
Contact details:
Health visitors name:______
Contact details:______
Social worker's name:______
Contact details:______
Team manager's name:______
Contact details:______
Registration category:*physical abuse:*sexual abuse:
(*circle relevant section/s)*emotional abuse: *neglect:
*not registered:
CHILD PROTECTION BIRTH PLAN. (This section to be completed at the conference)
1)
Agreed birthing partners name's. / Status.2)
Persons name's who are to be excluded from the Maternity Unit. / State reason.3)
Name's of any person who may have access to the Maternity Unit but whose conduct and behaviour may pose difficulties. / Status.NB Any difficult or disruptive behaviour within the hospital will automatically involve the hospital security and police and those persons will be removed as per hospital policy.
4)
Personnel to be notified (include EDT if required) / Status. / Details.On admission to hospital:
Following birth:
5)
Will the Child be separated from Mother:-
i) On Delivery Suite following birth:Yes / No
(and transferred to SCBU as designated place of safety)
ii) On discharge from Postnatal Ward:Yes / No
6)
Contact following birth:
Mother.
i)-supervised on Delivery Suite:Yes / No
ii)-supervised on SCBU:Yes / No / Access Denied
Father.
i)-supervised on delivery Suite:Yes / No / Access Denied
ii)-supervised on SCBU:Yes / No / Access Denied
iii)-supervised on Postnatal Ward:Yes / No / Access Denied
By Whom:
Any other person - details:
i)-supervised on Delivery Suite:Yes / No / Access Denied
ii)-supervised on SCBU:Yes / No / Access Denied
iii)-supervised on Postnatal Ward:Yes / No / Access Denied
By Whom:
7)
Does the Local Authority intend to seek any Court Order as part of the overall plan following the birth:
Yes / No
Details:
8)
If there is any attempt to remove the baby from hospital, without agreement, are hospital staff to immediately contact Northumbria Police and request the baby is taken into Police Protection:
Yes / No
9)
Will any pre-discharge meeting be needed:Yes / No
Details:
10)
Is baby is to be discharged from hospital to an alternative carer: Yes / No
If ‘Yes’ details are to be provided below if known or provided as soon as possible when known: (If a foster carers whereabouts are to remain confidential then this information is NOT to be included in any copy provided to the parents – be clear about this when submitting for typing).
Name:
Status:
Address:
11)
If Mother and baby are to be discharged home together detail any action and support that are to be noted:
12)
Other issues to be noted: