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.
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.
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.”