Serious case review criticises services’ ‘over optimism’ of ‘start again’ approach

Serious case review says historical information did not inform decision-making despite five of the parents’ children previously being taken into care

scared child
Image: Fotolia/mizina

Professionals were “over optimistic and unrealistic” in their assessment of two parents’ capacity to care for their children when the mother became pregnant years after five of their children had been taken into care.

A serious case review into the neglect of two children, ‘Charlie’ and ‘Charlotte’, found problems with the ‘start again’ approach taken in Durham.

Charlie was born in 2007 and Charlotte in 2010. Both remained in the care of their parents from birth but were eventually placed into foster care aged 10 and seven.

The neglect has had a “lasting impact” on their health, including sight problems and tooth decay, due to them missing numerous medical appointments. However, the review said missed medical appointments “were not always recognised as a serious symptom of chronic neglect by professionals”.

In 2001 another local authority had removed five children from the parents’ care because of concerns about severe neglect and physical and sexual abuse.

The family’s history was “the single most important indicator that parents were highly unlikely to ensure that the children’s health needs were met”, it added.

The review said Durham local safeguarding children board should ensure an initial child protection conference was automatically convened when a parent becomes pregnant and there had been a history of care proceedings, “regardless of current family circumstances”. If this was not considered necessary, a “clear rationale, with legal advice” should be provided.

‘Simplistic and unsafe assessment’

An assessment in March 2007 when ‘Charlie’ was 10 days old concluded that “the current situation has been assessed and found to be acceptable in terms of meeting the needs of a child”.

However, the review said that, given what is known about neglect and about the parents’ history, this assessment, said to be carried out over a very short time period was “overly optimistic, simplistic and unsafe”.

An initial assessment had been triggered by a referral from a midwife in October 2006 when the mother became pregnant with ‘Charlie’.

Concerns were identified due to the family history of child protection issues, though an assessment regarding the unborn baby did not include information about historical concerns of sexual abuse.

A decision was made at some point following the March 2007 assessment to manage the case at Child in Need (CIN) level, but these arrangements closed in September 2007, and the review said it was “not clear” how many CIN meetings (if any) took place along with the outcomes and actions.

Within two months of this, ‘Charlie’ had missed his first eye care appointment.

The review said ‘starting again’ might involve an “unfounded assumption that a new baby, or a different partner, presents an opportunity for the family to embark on a more successful period of parenting, without adequate professional reflection about whether the parental capacity to care for the child has in reality changed”.

But such a strategy “prevents workers from having a clear and systematic understanding of a case”, it added.

Historical information

Durham LSCB said it will “ensure that better processes are in place to protect children” where there is a history of care proceedings and a parent becomes pregnant again.

It also said multi-agency protocols would be put in place to “highlight where children are not brought to appointments so that, if necessary, relevant interventions can be made at the earliest stage”.

It added: “The LSCB has agreed that ‘working together’ and tackling ‘neglect’ are Board priorities and actions arising from the serious case review have and continue to be progressed by each agency.”

No consideration of sexual abuse

The review said indicators of potential sexual abuse were “not considered as an ongoing or longstanding concern”, and no overview of reported incidents of sexual abuse was used to inform risk assessments.

During 2008 two of the parents’ older children alleged they had been sexually abused by both parents. Durham children’s social care reviewed the information held by the local authority where the parents had previously lived and the allegations led to a criminal investigation, but no offences were revealed and Durham agencies took no further action.

The fact that no criminal proceedings against the parents took place despite as a result various allegations and investigations “may have influenced decision making and practice,” the review said.

The review recommended Durham LSCB and partners outline to practitioners how the thresholds for evidence in criminal and civil proceedings differ, and what this means for children where physical or sexual abuse is alleged or suspected.

“Specifically there should be a focus on those cases where the evidential threshold for criminal proceedings is not met but the probability of abuse having taken place is high and what this means for decision making and practice.”

It also pointed out that both parents were possibly victims of childhood sexual abuse and exploitation, and that “this can also be an indicator that their own children were more vulnerable to sexual abuse”.

Children’s views not sought

The review said there was “no information to suggest that Charlie and Charlotte were seen on a regular basis independently of their parents”, or that their wishes and feelings were sought.

“It therefore follows that they were unable to contribute to assessments of risk, planning and decision making,” it added.

“However it is important to note that the children had on occasion made disclosures of domestic abuse, alcohol misuse by their parents and of being hungry. This information did not contribute to assessment and decision making and the parents were able to deflect this.”

The review said Durham LSCB and partners should “ensure that practitioners and line managers are able to evidence that children and young people have been listened to and their wishes and feelings have been understood, respected and taken into account in decision making, risk assessment and planning. This should be a core (and clearly recorded) element of all work at Child in Need or Child Protection levels.”

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5 Responses to Serious case review criticises services’ ‘over optimism’ of ‘start again’ approach

  1. Tom J February 20, 2018 at 11:14 am #

    ”ensure an initial child protection conference was automatically convened when a parent becomes pregnant and there had been a history of care proceedings, “regardless of current family circumstances”

    – This is risk averse practice! So I do a full in-depth assessment which finds that the parent has fully moved on BUT I am taking the parent to ICPC anyway because although I have assessed that the circumstances to be completely fine we have a procedure in place which takes you to ICPC regardless.

    Some of the ICPC’s will be utterly bizarre! ‘Hello chair, I have absolutely no worries, the parent has fully moved on from where she was ten years ago, and all agencies are happy, but we are here to ‘play it safe’ and ‘tick a box’

    • James February 21, 2018 at 2:17 pm #

      I agree, as I can see the comment of the LA being risk averse if this then takes place. Seems Social Workers can not win either way.

  2. Ann Edwards February 21, 2018 at 3:13 pm #

    I think you should read the full report before deciding this recommendation is risk averse. In fact the recommendation in full says that if a child protection conference is not thought to be necessary then a clear rationale should be provided with legal advice. But the assessment in this case did not take into account the history and was perfunctory. There was no rationale as to why a child protection conference was not necessary. Parents proceeded to neglect these 2 children in much the same way they had neglected the 5 children who had been removed some 6 years earlier. And the neglect started almost immediately. Had all the agencies been on board with the issues from day 1, with a child protection plan, then there might have been better oversight and the children’s lives may not have been blighted.

    There are many issues relating to the inadequate response to the abuse and neglect of these children which deserve discussion but to mention two underlying omissions that puzzle me. It seems there was no assessment of mother’s learning difficulties in the previous care proceedings, at least there is no reference to such an assessment ( have I missed this?) Which leads on to the second, it seems the papers relating to the care proceedings were not read when the case was picked up in October 2006. It is inconceivable that, if they had been, the social work team would not have identified the need for a child protection plan, one element of which surely would have been management of health needs.

  3. ANGELA February 22, 2018 at 7:32 pm #

    First the risk needs to be recognised and understood .Unless you know what the risks are you can’t make an informed decision or an informed assessment this is not risk aversion .

    • Tom J February 23, 2018 at 1:22 pm #

      Angela I think you misunderstand that an ICPC is. By your logic you would put every case to an ICPC in order to understand risk.

      An ICPC is called once its assessed and jointly decided that there is a risk through an assessment and subsequent strategy meeting.

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