Social workers who felt pressurised to balance casework and performance targets prematurely closed the case of a baby who later suffered life-threatening injuries, a serious case review has found.
The report by Norfolk child safeguarding board found a series of failings in decisions made by social care, health and partner agencies in the lead up to the 10-month-old being hospitalised in May 2015 after he was beaten by his father.
These included a “premature” decision by Norfolk children’s services to close the boy’s case two weeks after a child protection referral was made in February 2015. An earlier referral made in October 2014, after the father assaulted the mother while she was carrying the boy, was also closed.
On both occasions, the social care assessments were flawed and left assumptions about the boy’s safety “unchallenged”, the review found.
The panel heard that social care teams were under “strain” at the time. Practitioners said they faced long journeys for home visits at the time and struggled to balance these alongside pressure from the council to meet performance targets.
The council’s “acute” focus on meeting timescales was born out of a poor Ofsted inspection, the review found.
‘Pressure’ to close cases
Social workers felt this had a “direct effect on threshold decisions and the thoroughness and quality of casework undertaken”. They also told the panel that managers at the time had been “pressurised” to close cases to relieve the demand on frontline workers.
The review criticised the council’s decision to close both referrals by sending a warning letter to each parent about the child protection consequences of children being exposed to domestic violence. Warning letters are “not recommended” as they potentially increase rather than reduce risk, the review found.
The review acknowledged that the incidents covered happened while agencies, including children’s services, were undergoing a structural overhaul.
It said that changes in children’s services – including using Signs of Safety and a new operational structure – had improved the situation for social workers and other agencies since.
Other issues identified by the review included:
- There was “widespread confusion” among agencies about the application of local child safeguarding thresholds.
- There was a poor understanding of how social care applied their step-up or step-down processes or how ‘closure’ decisions were made.
- Poor communication between agencies meant decisions remained “uninformed, unchallenged and sometimes not communicated at all”.
- NHS health visitors’ input into the case was flawed, partly due to those services being in a “state of flux” at the time.
- An “inexperienced” health visitor’s assessment led to the father being referred to a parenting programme that was ill-equipped for his complex needs.
- “Systematic” problems with NHS IT systems meant information recorded by health professionals remained “hidden and unknown” to other agencies.
- Meaningful engagement with the father about his parenting was “negligible” despite a number of professionals knowing about his troubled past.
- The risks associated with domestic abuse were not fully realised and safety planning assumed a “low priority” in care plans.
The mother and father split up after the domestic abuse incident but were living together again by the time the boy was hospitalised with the serious injuries. The review found agencies had a “generalised misunderstanding” of how risk could increase following a change in circumstances.
“There is evidence that when the family reconciled and moved into their own home away from their extended family support, professionals did not consider fully what those changes might mean,” the report said.
“As a result the risk assessment and level of support stayed the same, or in the case of the health visiting service was considerably reduced.”
Cathy Mouser, Norfolk council’s assistant director for social work, said: “Since Case R, we have introduced a stronger audit process to monitor social work practice and have improved the quality of social worker assessments of children and the oversight of casework by managers.
“Our new Social Care Improvement Plan emphasises how social workers need to build relationships with entire families so that the safety and wellbeing of any children is considered with the full knowledge of the family’s situation and background.
“The work our social workers do is invaluable and extremely challenging and we always strive to find ways to improve ways of working which helps all of those individuals and agencies in Norfolk who strive to protect children across the county.”