Nottinghamshire serious case reviews reveal safeguarding failings

Two serious case reviews published this week have revealed failings on the part of agencies in Nottinghamshire to act on child protection concerns.

The two cases late 2007 involve the death of a four-month-old girl, known as Sarah; and injuries to an 11-month-old boy, known as John, who was assaulted by his mother.

Both cases involved parents with a history of mental health problems and substance misuse and both reviews found child protection procedures should have been instigated but were not.

Sarah’s case

Sarah’s case was recorded as a Sudden Infant Death, however her father, who had a history of mental health problems and substance dependency, and mother, who was also drug dependent, had long been known to agencies.

Seven referrals had been made over three years to children’s social care about Sarah’s older sibling, the parent’s first child, because of bruising and concerns over the impact of the parents’ drug misuse.

Legislation and procedures not followed

The review found that on two occasions legislation and local procedures should have led to the older child being subject to child protection enquiries, and that decisions were sometimes made without reference to any assessment or risk analysis.

It said there were weaknesses in the overview exercised by social care managers, and in supervision, while the safeguarding board’s guidance on assessing the impact of substance misuse was not used to inform case work.

The review’s recommendations included ensuring all children’s social care staff and managers had clear guidance on thresholds for determining the status of referrals.

John’s case

In John’s case, there had been a range of concerns before his birth about the parenting ability of his mother, who had poor mental health and a history of substance misuse, and had had one child removed.

The review said that given this, a pre-birth referral should have been made to children’s social care as soon as it became known that she was pregnant with John, but this was not done until a month before the expected birth. John was born prematurely which meant that a multi-agency meeting was only held after his birth.

The review also found that there had been no assessment of the role of John’s father, despite him being a regular visitor to the household and there having been reports of domestic violence.

Child protection procedures should have been instigated

It concluded that there were points between John’s birth and the incident leading to the SCR where child protection procedures should have been instigated but were not, including one incident of unexplained bruising that was not investigated.

The review’s recommendations included the expectation that children’s social care should carry out a core assessment in relation to any child (including an unborn child) where a sibling has been removed because of concerns about significant harm.

John’s mother has since been convicted of assaulting him.

New director

Nottinghamshire Safeguarding Children Board said action plans had been implemented to deal with recommendations in each case, and that the council had appointed a new director of children’s services, Anthony May, in the meantime.

May, who is also chair of the safeguarding board, said: “The reviews concluded that there were problems in the way in which these families’ needs were assessed. We took immediate action to improve in the areas highlighted by the reviews. These include changes to management, staff and processes.”

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