Serious case review flags ‘toxic trio’ of risks to baby who suffered injuries

Review says multi-agency approach is vital in cases involving domestic abuse, mental illness and substance misuse

Safeguarding cases involving the “toxic trio” of domestic abuse, mental ill-health and substance misuse require a multi-agency approach, a serious case review has found.

The serious case review by Bracknell Forest Local Safeguarding Children Board examined a case where a two-month-old baby known as Child C had its right leg broken in 2013.

It found that the various agencies involved with the family did not work together effectively leading to individual services making decisions without a full picture of the family’s history and situation.

The review said children’s social care over-relied on information from health professionals, who felt there were no concerns, despite being aware of the wider family context.

Equally when children’s social care reviewed the family’s child in need plan in May 2012 and decided to close the case, it made the decision without input from health professionals who held relevant information.

Lack of action

“Overwhelmingly, this case makes clear that over-reliance on the opinion of health organisations or on children’s social care alone is to be avoided and all agencies must bring their own expertise to these difficult decisions,” concluded the report.

While the review found many examples of “highly effective inter-agency working” even when information was shared the response of the agencies involved was sometimes lacking.

This was the case when, a few days before Child C was taken to hospital in October 2013, the mother called 999 after an alleged incident where the baby’s father pulled out her hair and smacked her head against the floor while Child C’s sibling, a toddler, attempted to separate them.

“Police, children’s social care and health visitors were aware of the incident, yet there is no evidence that the emotional impact of C’s sibling witnessing domestic abuse was considered,” the review said, adding that there was also no evidence that any agency involved was minded to challenge that lack of action.

The review said it would have been useful if the police told children’s social care about incidents they had not classed as domestic abuse alongside other softer information they held about the family.

However, it added, social care could have requested that information as part of the assessment process or held multi-agency discussions that would have allowed that information to have been shared.

‘Toxic trio’

“Cases involving the toxic trio of domestic abuse, mental health issues and substance misuse cannot be worked effectively by any single agency,” the review emphasised.

The review also noted ambiguity in Working Together to Safeguard Children 2010 led to a family support worker supervised by an assistant team manager being appointed to handle the core assessment because the guidance says an experienced social worker must “lead” rather than undertake this work.

In response to this Bracknell Forest children’s social care has proposed to risk assess cases when deciding who carries out core assessments.

Alex Walters, the independent chair of the safeguarding board, said good progress has been made by agencies to address the problems raised in the review, which was delayed due to criminal proceedings.

These changes included training social workers on the importance of family history, holding regular case file audits and creating regular opportunities for cases to be discussed with adult social care.

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