Lack of reflective supervision hindered action in baby death case

Serious case review also highlights lack of information sharing between adult and children’s services

A lack of reflective supervision and information sharing between adult services and children’s social care has been highlighted as problems in a case where a baby died.

A serious case review carried out for an unidentified local safeguarding children board examined the events surrounding the death of Baby V, who was found dead aged six weeks old in November 2014.

Baby V belonged to a family marked by chronic drinking, domestic violence and mental health problems that had brought his parents and the father of his two teenage siblings into regular contact with multiple services across a number of neighbouring local authority areas.

The three adults in Baby V’s life repeatedly mislead services as to the extent of their drinking and their contact with each other.

On November 27, 2014, the mother took Baby V to his father’s home. What happened during the next 48 hours is unclear but on November 29 an ambulance was called to the father’s address and Baby V was found to have been dead for sometime.

The cause of Baby V’s death was “unascertained” but the parents had been drinking heavily and were later convicted of child neglect.

Reflective supervision crucial

The serious case review found services too often believed what the three adults involved told them and concentrated on their needs rather than those of the three children.

It said that a lack of good reflective supervision was a factor in services’ willingness to believe the adults despite the build up of evidence contradicting their claims.

“One of the most persistent and problematic tendencies in human cognition is a reluctance to revise an initial assessment of a situation,” said the review.

“Reflective supervision is crucial when addressing cognitive issues. These types of erroneous thinking and decision making are unlikely to be recognised by the individuals themselves.”

Think family

The review noted that adult services held a more accurate picture of the family’s situation than children’s social care but did not share this information effectively.

“The needs of the adults in this family were overwhelming and their needs dominated contacts with agencies. The review has highlighted the need for adult services to ‘think family’,” said the review.

“This problem was exacerbated by the myriad of services accessed by the adults that crossed several other areas, hospital trusts and GP practices.”

Section 11 process

The review recommended that the local safeguarding children board uses a Section 11 process to require all agencies involved to report on the effectiveness of their supervision and management processes so that the work of frontline professionals is scrutinised and challenged.

The independent management review carried out by children’s social care following Baby V’s death also echoed the recommendation.

This review concluded that practitioners should have “effective supervision that allows them to reflect critically on factors that could impact their practice including workloads, personal biases and intuitive responses”.

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2 Responses to Lack of reflective supervision hindered action in baby death case

  1. Maria March 26, 2016 at 7:53 pm #

    I just find this time and time again with social workers. I don’t know if it’s the time & workload issue but they accept without question what adults in families tell them and there is a lack of forensic assessment 🙁

  2. Speedo March 28, 2016 at 11:44 am #

    The headline for this article invites a criticism of “cherrypicking” one recommendation from many. This SCR is extremely informative about the complexities of CP work across agencies and needs to be read in full.

    Eileen Munro was insistent that her reforms needed to be taken as a whole package without a process of selecting preferred options and this report should be treated likewise.

    However, this SCR distinctly lacks a robust analysis of the working day to day culture of the LA Children’s Dept concerned, its staffing levels, its workloads, its overall level of professional expertise, both management and SW skills. This is common to most SCRs and fails to reflect the Munro view that SCRs should follow leads from engineering and the aircraft industry. Here, the culture of the workplace is always regarded as highly relevant as it sets the essential backdrop to understanding the “Human Factors” element. This SCR contains no commentary on how relevant SW staff viewed their working environment.

    Without utilising this paradigm it is self evident that we will continue to struggle to better understand the relationship between the complex systems of children in need (and their families) and the staff of the agencies that attempt to serve them.