An understaffed social work team’s “inappropriate” decision to close an investigation into concerns surrounding an unborn baby ended their involvement with parents who went on to seriously harm their other child a year later, a serious case review has found.
The review by Leicestershire and Rutland Local Safeguarding Children Board examined events leading up to injuries caused to Baby C, who was taken to hospital when one month old with multiple rib fractures and a brain injury. His father was charged with grievous bodily harm and his mother with an offence for which she received a suspended sentence.
The investigation found opportunities to intervene were missed across multiple agencies including the GPs, health visitors and midwives that spent most time with the couple. A police officer also failed to make a referral to social services after being called to a row between the parents. The officer “incorrectly” assumed there was no requirement to refer concerns about an unborn child.
The review’s learning for social services largely centred on a decision to close a case involving the parents a year before the injuries to Baby C. The local authority’s housing department had made a referral to children’s services raising concerns about conditions in the parent’s home.
At the time the mother was pregnant with Baby C’s older sibling. The review found that under pressure social workers had closed the case before visiting the family or the house.
“Nearly a month after the referral had been received Social Worker 1 told the team manager that she had been unable to contact mother, but that the Housing Officer had reported that the home conditions had improved and they had no police information regarding father,” the review found.
An assessment was signed off by a manager as being “comprehensive” and one which “investigated the concerns”. However, the review said “this clearly was not the case” and the assessment was in fact only an outline of the process followed.
The case should not have been closed as an assessment without meeting the parents or viewing the property was not appropriate and “meant that the concerns raised by housing about the unborn baby were unaddressed,” the review found. The assumption that the mother’s non-engagement was a matter of her choice, rather than an “avoidance tactic” also went untested.
The reasons for the closure were not shared with housing, so that department had no opportunity to comment on whether their concerns had been sufficiently addressed, the review added.
The case closure meant the family had no more engagement with social workers. The incident involving Baby C happened over a year later.
The report acknowledged “pressures” on the local authority duty and assessment service that had responded to the initial concerns.
“The assessment was required to be undertaken in 10 working days, and these timescales were closely monitored as part of the performance framework. Nationally the timescales became an important criterion for success. This has now changed.
“The team were also understaffed, and experiencing a high volume of work, they had to prioritise what they saw as the most serious cases. This all had an impact on decision making in this case. Work has been undertaken to improve assessment practice,” it said.
The review concluded that health professionals did not know about concerns regarding domestic abuse, suspected drug and alcohol use, anti-social behaviour or the mother’s “ambivalence” towards her second pregnancy.
“This lack of information meant that they were not able to evaluate the impact of these risk factors on the wellbeing of both young children or assess the parent’s circumstances accurately.”
The review recommended that children’s services should, in all cases, give feedback to a referring agency about the outcome and the rationale for the decision. The service should also ensure a robust relationship with the midwifery service for cases where an unborn child is of concern.
The review highlighted several areas where practice had changed since the incident. Housing and children’s services have co-located in the area of the county of concern, and police officers cannot close a case without having established and recorded information regarding a domestic incident and ensuring the safety and wellbeing of people involved.
Children’s services also record all domestic abuse notifications, regardless of police grading, and clear decisions are made on the seriousness of the incident.
Paul Burnett, independent chair of the Leicestershire and Rutland Local Safeguarding Children Board, said: “The review makes it clear that professionals recognised these were young and vulnerable parents, and provided appropriate support to them. But it also shows that more information should have been shared between agencies to help them gauge a more complete picture.
“Following this case, we’ve brought in a new information sharing agreement, ensuring that details are routinely shared in cases such as this to keep children safe. New guidelines are also in place to make sure that children’s social care only close a case once they’re satisfied that risks have been robustly assessed, and this evidences that the child will be safe without their intervention.”
Both children now live with a relative, and Burnett said Baby C is “thriving”.