Concerns about the sexual abuse of two children slipped “off the radar” following a “troubling” decision to change the category of their child protection plan to one of neglect, a serious case review has found.
The review into the case, where two children were exposed to sexual abuse and “chronic and extreme” neglect for six years in Cumbria before they were taken into local authority care, said that if services had continued to focus on sexual abuse, this might have given them more information to intervene earlier in the children’s lives.
“The shift in focus from sexual abuse to neglect demonstrated a lack of knowledge and confidence in dealing with sexual abuse, which included recognising age appropriate sexual behaviour in young children as a bench mark for judging abuse,” the review said.
The siblings were born into a family with a history of inter-generational sexual abuse, drug and alcohol misuse and concerns about domestic violence. They were initially put on child protection plans over concerns about their potential exposure to sexual abuse.
However, at a second review case conference, the child protection plan was recategorised to focus on neglect, which the review author said was “troubling” and meant no further assessment about the risk of sexual abuse was progressed.
At the time, the older sibling was exhibiting sexualised behaviour and had suffered with genital warts.
While a medical examination had not shown sexual abuse, the author said: “Had further assessments been pursued, information may have been obtained that should have led to earlier interventions to effectively protect the children. The known background of neglect should have signified that the children may have been more susceptible to sexual abuse as a result of the neglectful home environment.”
A key learning point from the review was that when the category of a child protection plan is changed, the conference chair must make sure the new plan considers outstanding actions, including assessments, that had not been addressed in the previous plan.
It added that professional focus on neglect meant there was less attention on the danger posed to the children.
“Concerning incidents included the injuries to [older sibling’s] feet in April and May 2010 which did not trigger timely and decisive action to adequately protect her, and there is a sense that professionals became tolerant and optimistic of the care given by grandmother and mother and applied a lower standard of care in the context of this very troubled family,” the report said.
“There is evidence to indicate that the myriad of adult issues overwhelmed not only the family but the hard-pressed, multi-disciplinary professionals involved who may have felt powerless to effect change in a family whose problems may have seemed insurmountable.”
Other learning points from the review were:–
- Professionals did not adequately consider the family’s own history of sexual abuse.
- Drug and alcohol misuse assessments appeared to be focused on adults and substance misuse, with little attention to the impact on the children.
- Practitioners found it “practically impossible” to prioritise children in face of adults’ problems.
- The case should have reached court sooner. The threshold for going to court was met in January 2013, but proceedings were delayed until April 2013.
- A residence order for the children to live with a grandparent was made following a “number of troubling incidents” which should have alerted social workers that the placement would not be in the children’s best interests. “There seems to have been a breakdown in communication and lack of proactive enquiry regarding the order by social workers.”
- The core group meetings happened within timescales, but there were question marks over whether it effectively scrutinised, updated and implemented child protection plans.
- The parents’ relationship was categorised by domestic abuse and a significant age gap between the parents, which should have alerted professionals to risks.
The review covered a six-year period up until the children were removed into care in 2013. It said since that time the local authority had changed as a result of national policy developments and inspections.
It said the practice in the case was historic and there was “overall satisfaction” the authority was making good progress in improving its children’s services, rated ‘inadequate’ in 2015.
Gill Rigg, independent chair of Cumbria’s local safeguarding children board (LSCB), said she had received “detailed assurances” from agencies that took part in the review about how practice had changed.
“Given the practice considered in this review is some 4-8 years ago, a considerable amount has changed to improve practice across the LSCB and its member agencies, and the lessons and recommendations from this SCR are reflective of that,” Rigg said.
“The work to implement the recommendations and to monitor their impact on practice will become part of the long term work of the LSCB and member agencies.”