Doncaster SCR not published until three years after baby’s death

A serious case review into the death of a baby was not published by Doncaster Council until three years after the incident, it has emerged.

The three-month old died as a result of Sudden Infant Death Syndrome in October 2004 after sharing a bed with his alcoholic mother. But the SCR was not published until January 2008, the council has confirmed.

In the meantime, another child also died from Sids in similar circumstances in the area in May 2006. The baby, aged seven months, had been sharing a bed with her mother, who had alcohol problems.

Last December, Ofsted raised concerns over delays in producing SCRs, warning that this did not give agencies a chance to learn lessons from tragic cases. The Working Together to Safeguard Children guidance states that any review should be completed within four months from the decision to carry one out.

But Ofsted’s evaluation of SCRs from April 2007 to March 2008 revealed that only five out of 50 reviews were completed within four months. Inspectors cited one area where an SCR took three years to complete. “In the intervening period another child died in similar circumstances. Had the first serious case review been completed on time and lessons learned identified and put into practice, the death of the second child might have been avoided,” the report said. Ofsted has refused to confirm whether this was referring to Doncaster.

A third Doncaster SCR last December highlighted further concerns over agencies’ handling of child protection.

The review into the death of a 10-month-old baby in December 2007, concluded Doncaster children’s services were “grossly inadequate” in their dealings with the boy, known as Child A.

The children’s services department had failed to respond to 10 referrals about the family.

The review found staff had “unmanageable workloads” and described the situation in the team dealing with the case as “chaotic and dangerous.” 

Doncaster Council this week confirmed that a further four serious case reviews were underway. Those still to report include the cases of Amy Howson, who died in December 2007 aged 16 months, and three-month-old Alfie Goddard, who died in May last year.

Timeline of Doncaster serious case reviews