Doncaster children’s services were “grossly inadequate” in their dealings with a child who died aged ten months, a serious case review has found.
The boy, known as child A, died last December of natural causes. His mother had a history of inadequate parenting and the father had been jailed for violent behaviour.
However, the review found that the children’s services department failed to respond to ten referrals about the family.
Chaotic and dangerous
The review said the situation in the team handling the case was “chaotic and dangerous”. It described “unmanageable workloads”, high staff shortages, poor communication and the use of inexperienced workers as fundamental problems.
The family were twice assessed by inexperienced practitioners, who did not carry out suitable assessments or call for further intervention. In one case the social worker focused on housing issues rather than the welfare of the baby and his older sibling, and took assurances from the mother at face value without questioning them, the report found.
The parents were found to have a “disorganised lifestyle” and were difficult to work with, refusing to engage with agencies.
The review said: “The referrals to [children’s services] were met with non-adherence to procedures, practice which fell below appropriate professional standards and a lack of engagement and effective communication with other agencies and the family.”
Three domestic violence related referrals, including one report suggesting that one of the children had been harmed, were made in the last three months of Child A’s life.
Children’s services did not respond until the third referral, and failed to implement child protection procedures or contact any other agency. No action was taken in the three weeks before Child A’s death.
While the post-mortem found that he had died of natural causes, the review said that there was no way of knowing whether Child A needed medical treatment before his death because he was never seen by a doctor.
Operated in isolation
The report said that the children’s services “effectively operated in isolation” from other agencies and that communication was “a one way street” in terms of the department’s failure to respond to referrals.
The review made five recommendations including improved use of pre-discharge planning meetings and better relations between the police and the probation services regarding the welfare of children.
The council is currently developing guidance on working with uncooperative families, due to be published in the next four months.