A lack of professional assertiveness in the face of high workloads and obstructive parents was a factor in agencies’ failure to protect a 10-day-old child who died, a serious case review has found.
The review into how agencies in Manchester worked to protect B1, a child who died after being laid on by their father, found that social workers had not been “sufficiently assertive” in pursuing contact with B1’s older siblings after the parents sought to stop services from talking to them alone.
The parents were unwilling to engage in services for fear of having their children removed into care.
“The level of obstruction and unwillingness to engage by the parents was never discussed and the response from key agencies such as children’s social care services was not adequate. The response was too often inconsistent and lacked enough purpose,” the review found.
This probably reflected individual professionals feeling “overwhelmed by their workloads and disruption in the lines of management and professional support”, the review said.
It added: “The reluctance to engage contributed to a ‘softly softly’ strategy being used to try to gain confidence and trust and undermined a more assertive approach that some professionals, including one of the child protection conference chairs, felt should have been pursued.”
The mother’s concern that social services would remove children from her care was a “dominant factor” in her relationship with services, and she had proved “very effective in hijacking the conduct of some important meetings” where she felt threatened.
“The parents remained in control of professional interaction and influenced decision making and were effective in preventing meaningful intervention,” the review said. It added that persistent avoidance, hostility or resistant behaviour needs to be taken very seriously because of the association with fatal child abuse and neglect.
The combination of overloaded professionals, in some cases with “excessive workloads”, with “manipulative and obstructive behaviour” from adults was a dangerous combination, the review said.
The family had a 10-year history with children’s social services, and the report acknowledged how a high turnover of social workers was disruptive to organising support and response to the family.
“The frequent changes in social workers had a negative impact on the quality of coordination of multi-agency work. Plans and agreements were not routinely circulated. A written record of discussions and decision of core groups was often left to individual professionals to make their own note.”
The team manager of B1’s pre-birth assessment was managing a team responsible for 92 statutory assessments, at a time when children’s services were being restructured and referrals were increasing, and it was with this background “an inadequate assessment was allowed through to pre-birth conference to avoid further delay”.
The pre-birth assessment was late, contained inconsistent spellings of children’s names, was “very superficial” and relied on the parents’ assertions.
The review also noted how the “apparent absence of neglect” in regard to the older siblings’ physical appearance “may have led some professionals to think the risk from the parents’ behaviour was less severe”. This was despite the fact one of the children had nine teeth extracted due to dental cavities, which was “evidence of potential neglect”. Although the siblings appeared very resilient in spite of their exposure to abuse and neglect.
Manchester Safeguarding Children Board accepted the reviews findings, and said it was not satisfied there was sufficient understanding and capacity to develop an assertive and informed response to resistant families. It said it would have a Learning and Development Sub-Group challenge agencies about the support given to staff.
Paul Marshall, director of children’s services for Manchester City Council, said expressed condolences to the family and friends who knew B1.
“Although the serious case review found that the tragic death of this baby could have been neither predicted or prevented by any of the agencies involved, there are always lessons that can be learnt, and we fully accept the findings of the review and have taken them on board,” Marshall said.
He added that, since the events of the review in 2013, caseloads have been reduced, there is a greater focus on management oversight and there has been work to improve the quality of assessments and challenge social work performance.
B1’s father was convicted of charges relating to child neglect in early 2015.