The botched implementation of “Reclaiming Social Work” on the Isle of Wight contributed to a three-month old baby suffering severe injuries as the result of being shaken, according to the serious case review.
The harm to Baby T was found to be both predictable and preventable, given the family history known to services and the fact children’s social care were contacted eight times with concerns without any assessment taking place.
The review criticised the implementation of the “Reclaiming Social Work” model, pioneered in Hackney, without the necessary checking of social work competence, change in culture and consultation with partner agencies. It was also the third restructure of children’s services in four years.
“The Serious Case Review panel and overview author are of the view that this reorganisation may have been hurried, ill-thought through and was responsible for some of the difficulties identified in this review.”
Social workers also reported being under pressure to reduce the number of child protection investigations and increase the number of Common Assessment Framework (CAF) interventions. This resulted in social workers ignoring the background information and downgrading the case at every opportunity.
Ofsted has recently rated the Isle of Wight safeguarding services inadequate and the island has voluntarily asked Hampshire children’s services to take over.
According to health records Baby T’s mother had a troubled history including reporting previous miscarriages and a still-born baby while still in her early teens, drug use, anxiety and agoraphobia, physical and emotional abuse from her mother, living homeless for a while and episodes of domestic violence from both of the fathers of her two children, a four-year old girl and Baby T.
While pregnant with Baby T, she moved to the Isle of Wight to where her mother and a close female cousin lived.
Even before Baby T had been born the cousin called social care with concerns that the mother was not coping and her small daughter was often having to “fend for herself”.
However, when the mother turned up to social services the following day to rebut such allegations, social workers accepted her story and determined it should be a CAF matter.
Repeated incidents of concern followed but all were resolved to be dealt with by a CAF led by a family support worker employed at the local children’s centre. Because the mother was seen to be engaging with the CAF process, she was rarely challenged and concerns were minimised.
Her eldest daughter was cared for by a variety of people. The mother often did not know where she was and, at times, was happy to let her sleep in the same bed as some of the men who lived in the house despite knowing they were not related.
After Baby T was born the mother’s ex-boyfriend (and father to her daughter) moved in with her. His presence was never challenged or investigated. If it had been, police and health records would have revealed he had an extensive criminal and mental health history involving violence, including domestic violence towards the mother.
However, the review noted that the mother often deflected questions about domestic violence or who the man was.
After Baby T was admitted to hospital with injuries, later found to be inflicted by the ex-boyfriend, the review noted that the actions of staff were “professional, thoughtful and compliant with procedures”.
“This professionalism is in contrast to much of the work that had preceded the event. This may be due to the fact that different staff members were involved. Or it may indicate that the island’s professional staff manage a situation better when they are sure of the situation they are in.”
The review made a number of recommendations:
For social workers and professionals
- Always consider the impact on children of the parenting they experience in relation to child development and attachment. Have an understanding of what is good enough so poor parenting does not become the norm.
- Include measurable outcomes in all child plans, including CAFs, and take action when those outcomes are not being achieved within agreed timescales.
- Ensure records contain specific descriptions rather than general terms such as “domestic violence” or “considerable concerns”.
- Use family trees and case chronologies on all cases
- Where domestic violence is actual or suspected, remove the perpetrator, rather than the children.
For the Local Safeguarding Children Board
- Ensure that pressure for cases to be dealt with at CAF level do not result in a lack of social work services to children-in-need.
- Understand and monitor the impact of changes to systems and structures within children’s services to ensure children continue to receive an appropriate response and effective challenge is made where this does not appear to be the case.