Serious case review identifies dangers of ‘block’ transferring cases in child protection

A council is revising its process for transferring cases between different children’s services teams in response to concerns raised by a serious case review into a baby’s death.

Sunderland council said it would review its approach after the investigation found “block” transfers meant important details about vulnerable children could be easily overlooked.

The serious case review was one of three commissioned by Sunderland safeguarding children board that were published this week. The other two investigations involved cases where babies in contact with services had been seriously harmed.

A report drawing out themes from the three reviews and practice over the 2011-2015 period in which the incidents took place was also produced. This identified repeated concerns over high social worker caseloads and turnover at the council and found safeguarding staff were “under considerable pressure” both in terms of times and resourcing.

Clear narrative

The safeguarding partnership operated at a “basic and pragmatic level only” and lacked a “clear narrative” as to what services aspired to for children, the report found.

“Without a clear statement of values guiding and underpinning the actions of those with responsibilities for safeguarding children and young people” there can be inconsistency, and outcomes can fall short of ‘good enough’,” it said.

The council, which was rated ‘inadequate’ by Ofsted in 2015, should do more to improve recruitment, retention and support for social workers and others working in safeguarding on the frontline, the report said.

It identified how understanding the role of males in families was critical to assessing risk, and there were conflicting views about the impact of illegal substances on parenting capacity, and the extent of which cannabis increases level of risk to children and unborn babies, among professionals.

“[Sunderland Safeguarding Children Board] must be confident that in key agencies, quality supervision of frontline practitioners and their managers is not compromised by broader organisational issues such as time constraints, capacity issues, and workload pressures.

“The board must ensure that when partner agencies undergo significant organisational change, it is provided with reports from those agencies, which demonstrate how risks to existing safeguarding practices and processes have been assessed and how they will be and are being managed.”

Apology

In a detailed response to the report outlining a series of work underway to address the issues identified, Jane Held, interim independent chair of the safeguarding board, said the serious case reviews had identified “common reasons” why the incidents took place.

“Those reasons are not excuses but are important to understand if we are to learn from what happened and improve how well we support other vulnerable babies and their families,” she said.

Held also apologised “unreservedly” to everyone involved in the cases.

“No one professional is individually culpable for specific failures. Indeed in each case there were hard working and dedicated individual professionals trying hard to improve things. There is also no direct causal link between this poor practice and what happened to each baby in any of the cases.

“That does not excuse the fact that these babies’ lives were badly affected by their experiences and by the quality of their family life. We (as well as their families) could have made their lives at that time, and did not.”

Held acknowledged and accepted themes found in the reports, such as pressures on the workforce, and an over-focus on the responsibilities of social workers diverting attention from the fact the whole system was not working well.

“The thematic overview report finds that overall the SCRs do not evidence endemic or systemic failures within Sunderland (across all partners) or, more specifically in Children’s Services Social Care at the time the SCRs covered. This is helpful, and provides a sound basis to build on.”

The serious case reviews –

Baby E

Baby E was four months old when she died. No-one was found to be at fault for her death, but services were involved over concerns surrounding neglect.

The serious case review found an “absence of assertive interventions” with E’s mother and her children, and the absence of “proactive, co-ordinated, system-wide action contributed to Baby E and her siblings’ continued neglect”.

“The pattern of referrals indicates the family were perceived by children’s services as having ‘low level’ needs and consequently the wider issues around risks in relation to substance misuse, domestic violence and mental health were never fully explored, or the Sunderland threshold model applied to inform decision making,” the review said.

Some work with the family was “uncoordinated and piecemeal”, and limited understanding about the boundaries of family support and child protection, it said.

Baby O

Baby O was five months old when he was taken to hospital with a non-accidental injury caused by the grandmother with whom he had been placed by the local authority. She already looked after two grandchildren under a special guardianship order.

Prior to O being placed with the grandmother, patterns of neglectful parenting “was not tracked or consistently monitored”, the review found.

“The threshold for children’s services intervention was very high and, when there was intervention, the practice with the family lacked effective reflection and management oversight.”

There was a failure to escalate and challenge inaction by children’s services, the review said, and there was lock of an effective system and collaborative working.

“The serious injuries suffered by Baby O could have been prevented if there had been more rigorous and timely planning had been heeded,” it said.

Baby W and Child Z

Baby W suffered a non-accidental injury, a skull fracture, aged 11 weeks. He and his older sibling were later adopted.

The review criticised out-of-timescale assessments that appeared “as a collection of statements but no depth of analysis was evident”.

“Poor analysis has been a continued and consistent theme and was identified in the recent Ofsted inspection and other SCRs in Sunderland, suggesting that lessons have not been learnt or embedded into frontline practice,” it said.

There wasn’t a thorough understanding by frontline professionals and managers of the unborn baby procedures.

It said the injury could not be attributed to a professional who knew the family, but the review was a “stark reminder for all agencies of the need for robust assessments and dogged challenges to young parents whose lifestyles have the potential to place their children at increased risk of harm”.