Religion: Country of Origin: Language Spoken: Communication Support: Interpreter Signer Document Translator Section 2a: Referrer’s Details Name of Referrer: Designation: Address: Date of Referral: Postcode: Contact Details: Section 2b: Reason for Referral Section 2c: Immediate Actions Are Immediate /Actions necessary to safeguard the unborn baby? Section 3a: Other Household Members (Incl. non-family members) Member 1 Member 2 Member 3 Member 4 Last Name: Alternative Last Name: First Name: Telephone No: Mobile No: Date of Birth: Relationship to Child/ YP: Language Spoken: Nationality: Communication Support: Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Section 3b: Significant Others (Incl. family members who are not members of the expectant mothers household) Other 1 Other 2 Other 3 Other 4 Last Name:
Alternative Last Name: First Name: Address: Postcode: Mobile No: Date of Birth: Relationship to Child/ YP: Language Spoken: Nationality: Communication Support: Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Interpreter Signer Doc. Trans Details Section 4a: Summary of Referrer’s Previous Involvement Section 4b: Referral Consent Is the expectant mother aware the referral is being made? Yes No If NO, please explain
Analysis : Ms Jones disclosed to the midwife that she had a Mephadrone addiction and she stopped using when she found she was pregnant. She had also self-harmed and with supports she is now doing well. She has attended anti-natal appointments appropriately and is reported not to have used drugs since. Her partner had been a heavy user of cannabis and the key worker reports that he has reduced his use immensely and now very rarely uses. The couple have agreed that the baby should not be exposed to anyone who under the influence illicit substances. The couple need to be highly commended regarding the positive changes to their lifestyle choices since Ms Jones became pregnant. It is still early days for the couple and whilst they have some extended family support, the pressure of a newborn baby may create tensions. Additionally Mr Hampton continues to use cannabis, albeit sporadically. The family have agreed that they would like some additional support, particularly in the early stages after birth as they recognise the commitment required to parent a newborn baby appropriately. Action taken or required : Gateway Team Manager reviewed assessment and agreed that threshold not met for pre-birth case conference. Agreed to proceed with Family Support Planning. Is C.P. Investigation being undertaken?: Yes No × Restricted : Yes No × Signed: Claire Smith Date: 24th December 2014 Date Completed: 24th December 2014 Appendix 3: Guidance to Completing a Pre-Birth Risk Assessment Antenatal Care: Medical and Obstetric History. When considering these issues it is important to be aware that the named lead midwife will have provided the expectant mother with choices about the place of birth and type of care
Significant Others Name DOB Relationship to Unborn Child PR? Address Family GP: Family Midwife: Family Health Visitor: Dates Parents/Carers Seen for Completion of Pre-Birth Assessment Name: Date(s) seen: Multi-Agency Involvement Agency: Person: Specialist Assessment(s) Agency: Purpose of Assessment: Significant Events Date Event