A children’s services restructure meant “corners were being cut” at the time agencies failed to properly investigate a torn lip suffered by a baby, a serious case review has found.
The report by Somerset Safeguarding Children Board found there were missed opportunities to safeguard the girl, who was taken to hospital with the injury in 2014, and her younger half-sister who suffered fractured ribs and a fractured tibia 10 months later. The two children were eventually taken into care.
The report said professionals should have shared more information with one another, particularly as the parents had “significant issues” in their lives including domestic abuse and drug misuse. Services should also have been more sceptical of the explanations for the injuries given by the parents, it added.
After the injuries to the older girl, known as child L, were discovered police and children’s social care decided not to carry out further investigation. Instead a child and family assessment was undertaken.
Professionals’ concerns had been “allayed” by the parents’ reaction L’s injuries. They sought medical help, the injury was a small size and they presented as being concerned for their daughter’s welfare.
The review said a child of this age was unlikely to have acquired the injury accidentally and police and social care should have been more suspicious of this being a non-accidental injury. However, it added that advice given to social care and police by medics should have been clearer.
A request for an initial child protection conference later made by a nurse was rejected because social care felt the parents’ cooperation meant a child in need assessment was more appropriate.
When a child protection investigation was eventually carried out it was “superficial and of poor quality”, the review found. The case had been allocated to an inexperienced social worker who lacked the appropriate training and the council also failed to offer him sufficient supervision and management oversight, the report found.
At the time “corners were being cut in terms of practice and supervision” due to the “major change and upheaval” in the department, reviewers found. It may also have led to partner agencies failing to challenge social care decision-making and having lower expectations of the services due to a “tacit acceptance” of the difficulties staff were facing.
The investigation made a series of “weak recommendations” that were unlikely to be acted upon and the case was closed by social services two months after the incident.
Eight months later, concerns were raised over injuries to the younger sibling, child J. This time the social services investigation was “more thorough and competent” and liaison between agencies was much improved, the review found. Care proceedings were launched shortly after.
The review calls for a review of interagency procedures, strengthened guidance on the use of face-to-face meetings, and improved management oversight and supervision across services. It also says children’s social services should review guidance on child and family assessments to make sure it is applicable to families with babies and young children, and includes advice on disguised compliance.
Sally Halls, chair of the safeguarding board, said: “This review identified a number of areas of learning. One that health and social care professionals need to be mindful of is the need for respectful uncertainty regarding the willingness of parents to comply with professional advice or oversight.”
“This is not to say the parents in this case were necessarily deceitful or manipulative, but situations arose which caused professionals to be unduly optimistic based on no evidence other than the parent’s expressing willingness to comply with the professionals care plans.”
Julian Wooster, Somerset’s director of children’s services, said the response to the second incident showed improvements were being made.
“A recent monitoring visit from Ofsted to children’s social care has also confirmed that progress is being made and that children and young people in need of help and protection receive a timely and effective response. Understanding of thresholds has been embedded across the partnership and social care managers have appropriate oversight of cases.”