Birmingham Safeguarding Children Board has highlighted major concerns over the treatment of mothers with mental health problems in three serious case reviews into child deaths and serious injuries.
Revised SCR reports published today – the originals were assessed as inadequate by Ofsted – also criticised inter-agency working and information sharing practices.
Another report, also delayed because of Ofsted criticisms, pointed to problems with supervision by the Probation Service, despite evidence of good practice in mental health services.
Council inadequate in safeguarding
The reports come with Birmingham Council’s safeguarding provision under government scrutiny.
Ministers issued the council with an improvement notice in February after it was judged as inadequate in keeping children safe in the 2008 annual performance assessment.
Neglect charge over drowned baby
In the first case to raise concerns over mental health services, a 22-year-old mother was charged with neglect by abandonment after her youngest child drowned in a bath at home.
The mother had previous contact with adult mental health services, which had found she suffered from depression triggered by her isolation living in a tower block, and the fact she had three children aged under four.
She was eventually rehoused from the flat to a house shortly after she miscarried during a fourth pregnancy, but the baby died within a month.
Agencies working in ‘silos’
The review said agencies in this case “tended to work in a silo fashion”, despite good work by individual practitioners, and called for GPs to liaise with health visitors and/or school nurses when parents presented with a mental illness that could impact on the well-being of their children.
In the second case, in which a mother had pleaded guilty to the manslaughter of her six-year-old son, the review said treatment for her depression and anxiety was mainly via GP appointments with “very limited specialist intervention”.
Adult mental health services were “not engaged”, it added, so there was no health assessment of the mother’s ability to cope with her children.
Milestones missed over potential risks
Agencies also missed a “number of milestones” when they should have shared information about her “recurring mental ill health and the potential risks to the safety and well-being of the children”.
The report recommended that GPs should flag concerns on their database when parents had serious mental health problems that could lead to safeguarding concerns, and communicate these to other health professionals involved in the case.
The third serious case review praised the “extraordinary” support provided by Birmingham and Solihull Mental Health Trust (BSMHT) over several years to a young mother who later stabbed her five-year-old child – who recovered from the multiple wounds – during a psychotic episode.
Uncertainty over social work roles
However, agencies were not always communicating with each other to ensure a co-ordinated approach, and were not sure about individual roles and responsibilities, particularly the difference between the BSMHT social worker and the child’s social worker.
Social care “did not support the other agencies by identifying a lead professional” to support the mother to care for her child, the report added.
The child was placed in care at one stage, after the mother was admitted to hospital, but was removed by the mother five weeks later, without any planning, because she was distressed that her child was in care.
The review said the mother may have benefited from respite care for her child, but social workers had “left the mother thinking that the only option was for the child to come into care”, discouraging her from pursuing help.
In the fourth case, concerning the murder of a young child by his mother’s boyfriend, the SCR found that the murderer was under the supervision of the Probation Service at the time and classified as posing a risk to children due to previous robbery offences against teenagers.
However, probation officers were not aware of his relationship with the child’s mother and believed he was living at his mother’s, not his girlfriend’s, address. They also failed to meet national standards, which require that officers meet with clients on a weekly basis for the first sixteen weeks of a supervision order, the first meeting taking place eight weeks into his order.
The report recommended that the National Probation Service West Midlands should ensure that all offenders identified as posing a risk to children – not just those classified as high risk - should be home visited within a month of leaving custody.