Health and care services overlooked the impact of “inter and multi-generational abuse” in a family where a toddler suddenly died, a serious case review has found.
Poppi Worthington was 13-months-old when she died in December 2012. A judge found she was likely to have been sexually assaulted by her father. Her father has not been charged and denies any wrongdoing.
The Cumbria Local Safeguarding Children Board review found Poppi’s family had a “complex history”. Her grandmother and mother had both been in care. Her mother was taken into care as a child due to fears of sexual exploitation. She was 27 when she became pregnant with Poppi and her twin, and had had four other children taken into care.
No long-term support
The review found Poppi’s mother received no support for the trauma of her own experiences or the trauma of having her first child taken into care. Social care professionals worked with the mother immediately after a care order for her second child was discharged but they, as well as midwives and health visitors who worked with the mother, failed to properly consider the impact of her past, the review found.
The report said: “There were no plans put in place for any long term support or intervention to ensure that MCN [the mother] and her children were safe and thriving despite the fact that there were several significant indicators that her capacity to parent may have been compromised by her own childhood experiences of trauma and abuse.
It added: “MCN had experienced significant historical traumas and loss which were, in themselves, clear indicators that her parenting may have been compromised and that her children could be at risk.
“There is no evidence that practitioners considered that MCN repeat pregnancies would compromise her ability to care for her children or that the repeat pregnancies were symptomatic of unresolved loss.”
Responding to the review findings, Dr Amanda Boardman, the safeguarding children lead at NHS Cumbria clinical commissioning group, said: “If professionals had put all the pieces of the puzzle together then early help should have been offered but at the time this tragic event happened early help was just starting. Now we have a much more robust system in place.”
The review found no evidence Poppi’s death could have been predicted or prevented but it identified several lessons for services.
It found the “critical importance” of family history needed to be considered, and it should have been highly relevant to any assessment of the mother’s needs for therapeutic and other support as she grew through adolescence and became a parent.
At a learning event held during the review, professionals told how several generations of families being involved with social care had become “normalised”. The report recommended better support for frontline practitioners to further their understanding of the needs and risks around women with the mother’s profile.
The review also urged professionals to show more curiosity and around fathers, and other males, who “associate with high need or complex families particularly where there has been a history of sexual exploitation or abuse”.
It also said professional thresholds of what is considered “normal” and “good enough” parenting should be the same across all families.
Gill Rigg, the chair of Cumbria local safeguarding children board, said: “Our deepest sympathy is with Child N’s [Poppi’s] family and those who knew her.
“Child N had very limited involvement with agencies during her lifetime, and when she did, she appeared well cared for.
“While the review has identified important learning regarding working with families with complex histories, there is nothing to suggest her death could have been predicted or prevented.”
An inquest held following Poppi’s death was quashed. A second inquest will be held later this year.