Babies in danger

Failures in implementing the current child
protection system, rather than the system itself, are to blame for
many child abuse deaths, argue the NSPCC’s Peter Dale, Richard
Green and Ron Fellows, basing their views on new research.

Babies under the age of one year are
statistically more likely to be the victims of homicide than any
other age group in the population. In our research
study1 we analysed cases where young children had been
seriously injured and where parental explanations for these
injuries were absent, inconsistent or discrepant with medical
opinion. In this article we focus on some of our findings and
recommendations drawn from the sample of research involving babies
who died from their injuries.

We analysed 17 part 8 review reports – part 8
review reports are inquiries undertaken by Area Child Protection
Committees (ACPCs) into cases where children have died or have
received serious injuries in circumstances giving rise to

The reports came from seven ACPCs and focused
on a total of 28 children in 17 families. Nineteen of the infants
died and two more sustained injuries resulting in permanent
disability. In every case except one, it was the only child, or the
youngest child in the family that was killed. A surprising
proportion of the families (over three-quarters) comprised natural
parents. Three were single mothers each with one child, and only
two were families with any natural parent and step-parent

As with the non-fatal sample reported in our
previous article (“Risk Radar”, 21-27 June 2001), the
susceptibility of babies to serious harm in the very first few
weeks of life was striking. Ten of the fatalities occurred before
the age of 12 weeks. The most frequently recorded injuries causing
or contributing to death were in descending order brain damage (for
example subdural haemorrhages), skull fractures, rib fractures,
other fractures (including neck) and poisoning.

Another striking finding was the high
proportion of fatal injury cases – about half – in which the
infants had previously been treated for suspicious injuries and
were subsequently re-injured with fatal consequences. In 13 out of
17 cases, the infant had died prior to the involvement of the
formal child protection system. However, only two of these were of
the type where violence erupted “out of the blue” in families where
there were no significant recorded concerns. Rather, in 11 cases,
the part 8 reviews concluded that the levels of known concerns were
such that child protection procedures should have been invoked to
assess the safety of the infants prior to the fatal events.

Two major problems are identifiable from the
part 8 review reports. These issues are also familiar from the
Laming inquiry into the death of Victoria Climbi‚. First, in
several instances social services classified referrals expressing
concern for the safety of infants (made by members of the public or
by health visitors) as “child in need” rather than “child at risk”.
In these cases, for whatever reasons (possibly lack of resources) a
“child in need” designation virtually amounted to a “no further
action” disposal. This clearly confused professionals from other
agencies who seemed unaware that their referrals to social services
about an infant’s welfare would not be looked into.

The second problem was of an almost total
absence of any form of assessment by social services in relation to
families they already had contact with. This resulted in babies
being left at unknown risk with parents who had identifiable
constellations of serious mental health problems, domestic violence
and substance abuse and where there were established concerns about
the care of the child. Sometimes acute concerns were evident from
the very earliest moments. In one case the parents had a furious
row in the hospital during labour culminating in the father
punching a hole in the delivery room wall. At the age of three
weeks the baby was admitted to hospital as failing to thrive. At
five weeks the mother reported to the health visitor and GP that
the father had lost his temper with the baby and put his hands
round his throat on a couple of occasions. Two days later the
father told the GP that he had “bad thoughts” about the baby, and
sometimes wished him dead. No psychiatric or child protection
responses were initiated. The father was ultimately charged with
murder following the death of the baby one week later.

In other scenarios serious concerns
accumulated over a much longer period of time, providing many
opportunities for child protection interventions and assessment.
Overall, the circumstances of the part 8 review cases highlight
ineffective child protection system case management. It was unusual
for a review to conclude that the local child protection procedures
were at fault. Instead, repeatedly, it was the failure to implement
well-established procedures by professionals of all agencies that
was the significant factor in cases where it was concluded that the
death had been preventable.

From our research as a whole, which has
focused on a total of 45 infants (0-2 years) from 38 families, we
conclude that a great many serious injury with discrepant
explanations (Side) cases, both fatal and non-fatal, are
preventable. We make a number of recommendations that we believe
would improve the quality and consistency of inter-agency child
protection practice. These include:

National child protection
We found a worrying significant randomness of
child protection system response to Side cases. Our conclusion is
that the quality of inter-agency child protection practice in
relation to investigation, assessment, case-management, monitoring
and the provision of family support and therapeutic services needs
to be subject to new specific national child protection

Assessments: In addition to
the implementation of the assessment framework, there is an urgent
need for the development of structured assessment protocols for
Side cases that provide greater consistency, reliability and
validity in formulating evidence-based recommendations to courts
about these particularly vulnerable children and their

Role of courts: Although the
research shows that judicial decisions are not infallible, in our
view all decisions to return or not return Side babies/infants to
parents should be judicial. This would be the most effective way of
reducing the significant inconsistencies in child protection case
management. And, at the same time, ensuring informed consideration
of child protection needs alongside fair and transparent process
for parents.

Monitoring of inter-agency case
In many cases it was apparent that poor case
conference practice resulted in the reinforcement of unproductive
processes and adverse outcomes. Some conferences formed case
management plans that were incomprehensible in relation to basic
knowledge and child protection principles. There is an urgent need
for the quality of inter-agency child protection case management to
be supervised, monitored and audited on a much more rigorous basis
by ACPCs. ACPCs should be given the duty and responsibility to
closely supervise inter-agency child protection practice in line
with new national child protection standards.

Strategic role of ACPCs in prevention
of Sides:
In our view a significant proportion (but by no
means all) of Side deaths and recurrences of Side injuries are
preventable. Every ACPC should set strategic targets for the
reduction in incidence of fatal and non-fatal Sides in their areas
over a five-year period. To achieve this reduction, each ACPC
should systematically monitor the incidence and child protection
case management process of Side cases. ACPCs should:

– Establish accurate figures for the incidence
of Sides in their areas.

Routinely hold part 8 reviews on all non-fatal Sides to infants
less than two years old.

– Commission external audits into the quality
of their part 8 review processes and reports.

– Revise part 8 review panels to include at
least one independent member, and implement person specifications
for chairpersons.

– Undertake an annual analysis of the findings
of all part 8 review Side reports and make this widely available as
a professional education document.

This research indicates that it is not the
structure of current inter-agency child protection systems that is
at fault in relation to preventable child abuse deaths. Rather, the
main problem lies in continual failures in the implementation of
the systems – particularly the lack of systematic evidence-based
assessments of the initial safety needs of infants who have
received suspicious injuries, and assessment of the risks of
recurrence of injuries.

Rather than dismantling the existing child
protection structure, which, it is believed, is a proposal being
considered by the Laming inquiry into the death of Victoria
Climbie, in our view ACPCs should be given an enhanced statutory
responsibility for ensuring the quality of inter-agency practice in
compliance with newly determined national standards for child

– Further information from e-mail address  

Richard Green is evaluation officer,
Ron Fellows is children’s services manager, and Peter Dale is
senior research officer at the NSPCC


1 P Dale, R Green, R
Fellows, What Really Happened? Child Protection Case Management
of Infants with Serious Injuries with Discrepant Explanations
NSPCC, 2002

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