Children’s services and partner agencies missed signs of the daily risks posed to a four-year-old girl who died after being fed prescription drugs over a six-month period, a serious case review has found.
Poppy Widdison, from Grimsby, was found lifeless with severe bruising to her buttocks in 2013. Her mother Michala Pyke and her partner John Rytting, at whose home Poppy died, are due to be sentenced next week for child cruelty and drugs offences.
The serious case review, published by North East Lincolnshire local safeguarding children board, criticised services’ “loose” approach to assessing parenting capacity and found Pyke had been able to “mislead professionals with apparent ease”.
“The review has also shown more disturbingly however, that despite the significant history known to various agencies, no single practitioner or service knew what life was like for [Poppy] or the extent to which she was exposed to risk and harm on a daily basis,” it added.
Lack of oversight
The report found that while Pyke was pregnant with Poppy, during which time she was in an abusive relationship with Poppy’s natural father, concerns over her ability to parent safely led to her other child being taken into care. Yet areas of risk for her new baby were never “fully recognised”, it found, ultimately leaving Poppy at risk of serious harm.
The review concluded that a robust child protection plan and parenting assessment should have been implemented once Poppy was born, given there were well-recognised concerns over the domestic abuse and around both Poppy’s parents’ drug taking.
It characterised the lack of both as being indicative both of “ineffective management oversight” on behalf of children’s services and of insufficient challenge from partner agencies. A core assessment was left unfinished because of a social worker being off sick, exacerbating the situation.
“Robust assessment is vital to safe planning,” the review said. “Without this, practice lacked clarity and focus and inevitably left [Poppy] at serious risk of harm. Ineffective assessment and analysis features often in serious case reviews, as does failure to identify or act on other factors affecting parenting capacity such as substance misuse, domestic violence and mental health problems.”
The review drew attention to a 2012 Ofsted report that identified low ratios of child protection plans relative to the number of open cases in North East Lincolnshire, along with a tendency for high thresholds of risk to be managed under child in need procedures. “[Poppy’s parents had] presented as a couple characterised by domestic abuse and drug addiction. It is difficult therefore to see a rationale as to why this case was not managed at child protection level,” it said.
In Poppy’s case, the review found, insufficient support had been given to her paternal grandparents, to whom she was informally placed because of fears regarding her parents.
Poppy was subsequently allowed to return to the sole care of her mother and father without further assessment. Her child in need plan was ceased when she was aged 13 months because her parents were believed to be stable on a methadone programme, but no lower-level family support was put in place. Among a series of recommendations, the review found that ‘step-down’ arrangements for children must be underpinned by updated assessments and multi-agency input into the child’s ongoing needs.
The review highlighted Pyke’s capacity for “disguised compliance”, or concealing poor parenting by actively working to deceive agencies. Early years professionals found Poppy to present neatly, though noted that she could often be withdrawn.
But it also criticised a “loose approach” on behalf of all agencies involved. A referral to children’s services from a family member, around six months before Poppy’s death, resulted in no further action being taken. It recommended that all such referrals, no matter from whom, be followed up by direct contact with the referred.
“Practitioners adopted a mindset of wanting evidence in support of allegations before acting, rather than searching for evidence to refute the allegations before dismissing their validity,” the report said.
Ultimately, neither professionals nor family members were aware of Pyke’s relationship with Rytting, a chaotic drug user who had been known to adult mental health services for four years prior to Poppy’s death. During Pyke and Rytting’s trial, a court heard that he had encouraged Poppy to eat sedatives because she was an “inconvenience” to their relationship.
The serious case review found: “Agencies and practitioners must give honest consideration to the conditions that make it easier rather than harder for service users to deceive professionals.
“This requires honest appraisal of professional practice, communication and how professionals can create checks and balances of our own judgements and subsequent actions. It noted that local children’s services had identified the need for better collaborative working, and that a multi-agency safeguarding hub (MASH) had since been set up, a Signs of Safety framework introduced and better management oversight implemented.”
Rob Mayall, the independent chair of the North East Lincolnshire local safeguarding children board (LSCB), said all findings and recommendations of the review had been fully accepted.
“The LSCB leadership board has implemented an action plan in response to the recommendations and to embed learning and informing practice,” he said.
“Due to the complexity of enquiries that have been necessary in this case, it has been conducted over a three year period. During this time, significant changes have taken place across North East Lincolnshire and much of the learning and many of the recommendations cited in this review have already been implemented.”