‘Over-optimistic’ social workers did too little to challenge neglect within family whose baby died, review finds

    Investigation into five-month-old's death finds practitioners were controlled by his mother, and had 'inconsistent' supervision

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    Social workers involved with the family of a baby who died from a brain injury could have done more to “explore and challenge” neglect he and his siblings experienced at home, a review has found.

    Five-month-old Eli Cox, from Kent, was found by a post-mortem to have sustained 28 fractures in the weeks leading up to his death in April 2016. He and most of his six siblings had been stepped down from child protection plans just two months earlier.

    Eli’s mother Katherine Cox, 33, and her partner Danny Shepherd, 26, were convicted last November of causing or allowing the infant’s death. The serious case review set out to examine the context of “neglectful and chaotic” parenting surrounding Eli‘s short life, which it noted had been an “important background factor” in similar cases involving physical assault.

    The review, for Kent Safeguarding Children Board, found professionals involved with the family, which was known to social services for over a decade, were sometimes “overly optimistic” when presented with small signs of improvement.

    As with a number of other recent investigations, it highlighted the dangers of ‘disguised compliance’ by parents – which in the case of Eli’s family was “thought about but not really tested”. The review, which acknowledged the difficulties of working with large families, also said social workers’ supervision was “inconsistent” and “not in line with policy”.

    Nonetheless, it concluded there was “no evidence to suggest any professional working with the family saw or could have seen any indication of the violence experienced by [Eli]”.

    Poor home conditions

    Kent council children’s services had been intermittently involved with Eli’s family since 2005. Support centred on poor home conditions and associated issues such as domestic abuse and drug and alcohol misuse – both of which the mother was reported to have been exposed to from an early age – and budgeting.

    The children’s school made a number of referrals because of fears about their development, appearance and personal hygiene, while the police also regularly raised concerns. Over 10 years the family were stepped up and down as things got better or worse, with all of Eli’s siblings being made subject to child protection plans for neglect in January 2015.

    During the first half of 2015, police were repeatedly called to domestic abuse incidents – perpetrated by both parents – at the family home.

    At school the children were “seen as guarded and possibly advised not to talk about home”, the review noted. There were “several reports” of them having injuries, one of which was feared to be non-accidental and resulted in a hospital visit and plans being made for more intensive work with the parents.

    New partner

    In September, two months after it emerged she was pregnant with Eli, Cox revealed she had separated from his father and had a new partner – Shepherd. He was joined in the household by a lodger, his cousin, whose addition to an already overcrowded house was deemed a “concern”.

    While Shepherd’s arrival coincided with social workers observing improvements to the home and apparent “signs [of Cox] wishing to change”, alarms were raised during the autumn around sexualised behaviour by the children – but not pursued. Frequent bruising was also seen on Jude, Eli’s two-year-old brother, believed to be caused by poor supervision but put down by Cox to clumsiness.

    “The children were seen at school, as mother would not let the social worker visit at home,” the review added. “The children reported that things were fine at home, but there was a suspicion they were being coached in what to say.”

    Even so, by early February 2016, when a child protection review conference was held, things were deemed to have improved to the extent that all the siblings except Jude were stepped down to ‘child in need’ level. This move – which not all professionals were happy with – included Eli, who had been subject to a child protection plan from birth.

    Despite two incidents of drunkenness, one involving the police, at the house in early March, social workers continued to observe apparent improvements, with Eli happy and “receiving appropriate care and stimulation”. A few weeks later, he was dead.

    ‘Possibility of groupthink’

    The review highlighted a number of shortcomings that had arisen during practitioners’ dealings with Eli’s family.

    Challenges caused by the number of children involved, combined with poor coordination between agencies, led to complicated, time-consuming contacts with the family. The review also found an apparent tendency for professionals to see the siblings as a group, not individuals.

    “[A] social worker’s composite reports to child protection conferences, drawing on other practitioners’ observations, as well as the social worker’s own, sought to provide a pen picture for each child,” the review said. “But these do not include a thorough-enough assessment of each child’s overall emotional and general development.”

    There was an apparent failure to explore whether the children, who “idolised” their mother, were showing signs of chronic emotional neglect, the review said.

    Some workers also lacked confidence around assessing significant harm and working with disguised compliance, while others felt it was hard to challenge social workers’ opinions in multi-agency settings. “A question arises about the possibility of ‘groupthink’ influencing practitioners who feel less confident,” the review said.

    Workers ‘kept at bay’

    Overall, the serious case review found there was “not enough challenge and scepticism about [Cox’s] capacity to change and sustain change”, especially given the family’s history.

    It added: “There was a view that mother knew how to keep workers at bay and what to say to please them. Disguised compliance was thought about, but not tested out or robustly challenged.”

    Men, meanwhile, had remained indistinct figures in the narrative, with Eli’s father successfully “absenting himself” from child protection procedures while Shepherd was an “unknown quantity” who should have been made part of assessments and reviews.

    On the part of two social work staff involved with Eli’s family, “inconsistent” supervision carried out by separate managers hampered coordination, the review concluded. “The two workers had regular conversations and shared information about their progress,” it said. “This does not, however, replace reflective questioning and advice by a third party as a ‘critical friend’ to challenge and inform the continual reassessment and proposed actions.”

    Among a series of recommendations, the review called for audits to ensure parents’ and carers’ capacity to change was properly assessed, and for strengthening of arrangements to consider children’s emotional development.

    It said Kent’s safeguarding children board should review how frontline workers and their managers were equipped to engage with “challenging” parents and carers around domestic abuse, as well as agencies’ supervision procedures.

    ‘Important lessons’

    Responding to the review, Gill Rigg, the independent chair of Kent Safeguarding Children Board, said all relevant partner organisations had now drawn up “individual action plans for improving the way they continue to work to protect children in the future”.

    A Kent council spokesperson said the review process had made it “clear there were important lessons for everyone to learn when working together to support complex families with multiple risks and challenges”.

    The spokesperson added: “The review process has identified a number of areas in our own practice we can improve, and we have worked very hard to provide better support and challenge to families such as these.”

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    17 Responses to ‘Over-optimistic’ social workers did too little to challenge neglect within family whose baby died, review finds

    1. Peter Endersby June 11, 2018 at 11:20 am #

      Could someone please explain how the lessons from authorities are not reflected on by other authorities? They are common problems and nothing new. Lessons seems to be learnt in a piecemeal fashion. If you are lucky enough as a child to be in authority with lots of historic “lessons learned” then are you getting better protection?

      There needs to be a national strategy to social work the current sytem is a scandal and fails often which is unfair to families and practitioners. Even within local authorities there are different approaches even between teams in the same locality. Social Work needs to get organised if it is ever going to be taken more seriously.

      • MrTrebus June 11, 2018 at 6:03 pm #

        I think someone in a Policy/procedure role is expected to diseminate ‘recommendations’ and incorporate into local practice. Unfortunately, no matter how fantastically detailed the assessment papetwork is, without sufficient numbers of frontline staff, we will continue to barely cover the basics.

    2. Tom J June 11, 2018 at 1:46 pm #

      The idea that all would be well today had the social worker only ‘challenged more’ is laughable.

      The reality is that there are hundreds and hundreds of families just like described above. The difference is that the overwhelming majority do not murder their child.

      Severe neglect cases are very much like a game of ”whack a mole” in terms of resolution of problems. I see that this was the situation in this case; head lice, poor supervision, drunkenness, lodger moves in, DV, bruising, dogs, mum pregnant, condition of home…

      These are tough cases to work with.

      ‘Quickly bring ’em all into care’ has been the government mantra with this type of family; but we have no evidence base that this leads to better outcomes for the children.

      Unfortunately there are no easy solutions; being more challenging will rarely work on it’s own. These families are time and resource heavy. Relationship based practice, quality supervision, resources and yes challenge are all needed.

      • Jane Benanti June 13, 2018 at 5:01 pm #

        I would say better ‘care’ for these unfortunate children whose physical and emotional development and educational attainment can be negatively affected for life. The parents are unlikely to change but the children stand a chance in care. No child deserves to live like that in a prosperous economy.
        Read Davies and Ward.

    3. Daisy June 11, 2018 at 5:08 pm #

      It is very difficult to work with families who are entrenched in multiple issues and who do not want to change. The social worker needs strong support from their practice supervisor and manager, as a well known tactic is for the parent/s to constantly complain about and criticise the social worker to detract attention from themselves. I have been in this position, trying desperately to work with the family, whilst being subject to a stage 2 complaint and being investigated for all the complaints the parent had made.

    4. A Man Called Horse June 11, 2018 at 6:34 pm #

      The Government have pursued Austerity and welfare benefit cuts for many years. Issues of poverty and child abuse are linked. If the state removed all children living with parents using Alcohol and drugs the system would be safer but would collapse due to cost. Chaos has increased directly inline with welfare reform and Government cuts. There is no doubt that the situation described above is common across the UK, too easy as one commentator here has done to blame Social Workers for the situation. Inequality, poverty and deprivation is now normal for a growing section of the population, some of these carers will kill their children and the Social Workers in this case were just unlucky. I will remind readers again Social Workers did not kill the child the mother did that by all accounts. You seek perfection in a high risk area you will never achieve it. Children will continue to die in chaotic families such as these. You want total safety remove more of them from their families. You have to understand that this will be very expensive and beyond what the state can afford. Much cheaper and easier to blame Social Workers and trash their reputations.

      • Anonymous June 21, 2018 at 5:42 pm #

        I agree with with you A man called horse. It’s always the SW s fault. Another Baby P. We are told time and again we are not health or MH professionals and as such we aren’t in a position to advuce or identify a child’s bones have been fractured. Police were clearly involved and had concerns of serious DV- could they nit have acted on their PP? SW remains to blame when anyone can have children and who are to prevent them from doibg so, without infringing on their HR!

    5. Colin D June 11, 2018 at 11:11 pm #

      Can I suggest that if a mother is not allowing children to be sent at home this isn’t ‘disguised compliance’ its fairly obvious non-compliance. People need to stop using that meaningless phrase.

    6. Paul June 12, 2018 at 12:58 pm #

      The rule of optimisim has been recognised since the 80s as has the issue of avoidance of men in child protection practice, poor multi-agency communication, inadequate supervisoon and issues around appropriate use of power and authority in social work practice. It is shocking that in a local authority that was graded good by ofsted less than a year after this child’s death occurred that we see these classic errors of professional practice. This is really about professional dangerousness and a failure to put the children at the centre – not just from front line social workers but it seems across all layers of management within the local authority and partner agencies. A revisit of the doh messages from research publications from the 1990s would not go amiss – it sets it out all there!

    7. relaxing zen June 12, 2018 at 10:31 pm #

      It is very sad that not enough has been done to protect this poor little baby. I see the comments on here saying dnt keep slagging off social workers. That’s all very well but what they are doing is missing the genuine cases with tragic results and harassing innocent families.they spend far too much time listening to vendetta neighbour calls when a child just has a tantrum rather than concentrating on real cases

      • A Man Called Horse June 13, 2018 at 11:38 am #

        You are not a Social Worker are you? We deal in shades of grey not black and white.
        When trying to navigate a minefield you might by accident step on a live one that blows up in your face. You mostly are dealing with probability, abusive parents are not going to admit they are unfit parents. Social Workers I can assure you never want a child death on their caseload. You might not believe this but most Social Workers remain very worried about the children in their care. If they get it wrong a child might die, think about that, think about what that means to them. The facts are that millions of people are unfit parents and just because they can physically produce children does not mean they can look after them. Society talks about deserving families and undeserving families, the result poverty on a scale not seen for generations, try being a good parent when you cannot afford food, clothes and many other things considered for a civilised existence. The state has to police these families to protect their children. Polite middle class society doesn’t wish to pay its taxes and these children as far as they are concerned are not as important as their children. Easy to blame Social workers take a goof look around at the society you voted for.

        • Longtime SW June 14, 2018 at 2:19 pm #

          Well said . . . . If the rich vultuires paid even a quarter of thier dues to the society they make thier money from, we would go a long way towards having a Health and Social Care system that was fought (and died) for by previous generations.

        • Anonymous June 21, 2018 at 5:45 pm #

          Here here A Man Called Horse!

      • Carole Marshall June 18, 2018 at 12:43 am #

        Fact, Relaxing Zen.. I have witnessed it with my own eyes.

        Decent parents being hounded while those who couldn’t spell parent, playing the game for social workers to get all their boxes ticked! Decent parents getting shafted, while indecent parents continue to be indecent and, get away with it!

    8. sad June 13, 2018 at 11:01 am #

      The rule of optimism is needed by mangers because without it children’s services would collapse. The most difficult part of social work is not working with these families but getting mangers to listen and not close too early but then that would mean working with the families for ever.

      It is much more complicated than just poverty.

    9. Ann Edwards June 14, 2018 at 8:54 am #

      Agree with sad’s contribution to the discussion. It is not just about poverty. On reading the full report, it does not appear that the serious neglect, and abuse including possible sexual abuse within this family was due to poverty. And money was found for drugs, alcohol and possibly cigarettes (though the latter is not referred to) also a bedroom in the larger property allocated to ease the children’s overcrowding, was given by mother to an adult friend of hers who had a history of violence and drug use and brought 2 more dogs into this already dirty and overcrowded house. Poverty makes it harder to raise children but it is not the cause of these children’s appalling neglect. A child died and his siblings are in care (presumably) and suffering from their early life experience. I disagree with an earlier contributor that there is no evidence that care leads to better outcomes. It is more complicated than that. What we do know is the longer a child is neglected the worse the outcome. So, when children come into care after prolonged neglect, especially emotional neglect, of course it will be difficult if not impossible to remedy. Simplistically, the care system is blamed rather than the impact of neglect. As other contributors say, we have to pay attention to lessons about how to assess and respond to this kind of case and see things from each child’s perspective. I think it helps to keep specific records, e.g. a detailed chronology for each child as well as the family as a whole, documenting everything and a summary of each concern and how it impacts on each child as well as of course any positives using various tools available. Poor dental care, not keeping children’s health appointments, constant untreated lice infections are not seen as child protection issues but when each of these omissions is part of a pattern of neglect of a child’s needs, it is relevant. There’s less risk of ‘over optimism’ when faced with hard facts and a visual record. I would add, there is a particular point in this review about heeding concern from the community and not sidelining workers from outside children’s services. Also, setting time limits and being clear about what will happen if positive change is not achieved.
      It is very hard to do this work but the consequences otherwise are costly to society as well as individuals. If only management recognised the benefits (including financial – in the long term!) of allowing professionals the time and resources to do it properly.

    10. jim June 18, 2018 at 2:27 pm #

      there should be some sort of mandatory safeguarding built into these cases whereby it should be a legal requirement in cases of neglect for a parent to submit their child for periodic medical checks, and at any time at the request of the social worker..so that the social worker does not have to take the word of a deceptive parent.[actions speak louder than words]

      Reluctance or failure to comply with such a request would cut through any nonsense and could just save a child’s life. Yes it could be an infingement on the parent’s civil liberties but only in cases were child protection concerns histories have been established