Social workers engaged in ‘formulaic’ thinking that limited their ability to appreciate the dangers faced by a three-year-old who was killed by her mother who was drunk-driving , a serious case review has found.
The review, carried out for the Dorset Safeguarding Children Board, found Dorset council’s children’s services’ approach to risk-assessing Louisa Pike’s situation “appeared not to deviate” despite increasing numbers of referrals involving her mother Alanda Pike.
“Opportunities were available to children’s services… however, the presenting concerns were never judged as being at a sufficient level to warrant a more joined up and holistic approach,” the review said.
Pike was sentenced to six years imprisonment last October after being found guilty of causing death by dangerous driving when she pulled into the path of a van, while under the influence and with Louisa in her backseat.
She had been assessed as “moderately to severely dependent on alcohol” in 2012, but this information went undiscovered by professionals later involved with her, from whom she successfully concealed the extent of her drinking.
The serious case review said the “thinking trap” fallen into by social workers, who only gleaned information from a limited number of other agencies, was “not unexpected in a busy, demanding and complex environment like a multi-agency gatekeeping service”.
But, referring back to a series of other reviews carried out in the county, it reiterated the need for more effective multi-agency working around families where alcohol or substance misuse were “dominant features”.
While 13 weeks pregnant with Louisa, the review found, Pike had been banned from driving for 30 months after being stopped while four times over the legal limit.
Shortly after the child’s birth in 2014, children’s services received an anonymous referral relating to alcohol and cocaine use in the family home. But this was closed as a “desk-based assessment” after contact with midwives and health visitors.
In April 2016, police were called to a supermarket in Hampshire after Pike dropped Louisa while intoxicated, leading to a children’s services referral. The case was closed after 19 days because of “a lack of corroborating evidence to support any ongoing risk”.
During spring 2017, in the months leading up to Louisa’s death in August, social workers investigated further reports of Pike being intoxicated, and on occasion driving under the influence.
During this period children’s services recognised a pattern of concerns, and at one point recorded the need to start a section 47 investigation.
But cases were repeatedly closed in the wake of home visits in which no alcohol was found, and Louisa seemed “happy and talkative”. On each occasion, pre-school staff and health visitors raised no concerns about her welfare or Pike’s parenting capacity.
The serious case review noted that while children’s services conducted child in need assessments on at least four occasions, “information from other agencies continued to conflict” with concerns.
“With the benefit of hindsight, this review is now able to piece together several strands of information, which had they been known and triangulated at the time would have likely resulted in a different approach to any formal assessments undertaken,” it added.
Crucially, the review found, practitioners did not make contact with Pike’s GP, the only other professional to have knowledge of her 2012 assessment for alcohol dependency.
“Consent to share information about the individual to which the information relates is not needed if there are concerns about safeguarding and promoting the welfare of children at risk of abuse or neglect,” the review said. “In this case, it seems the level of professional concern had not reached a threshold in order to dispense with consent; the weight of information did not appear to support greater intervention.”
Reiterating the benefit of hindsight, the review added that the “more robust route” of a child protection investigation would have been beneficial in gathering information and making multi-agency decisions.
“Seeking information from new sources to either confirm or disprove any hypothesis formed is not unreasonable given the escalating number of episodes where the mother was reported to be using alcohol,” it said.
Citing earlier serious case reviews as well as recent British Medical Association research, the report said that Louisa’s death had highlighted the “inherent challenges for professionals when working with parents who use, and misuse, alcohol”.
The review found that there had been “little emphasis” within Dorset’s safeguarding training on parental alcohol use, and its potential risks to children.
In common with some other recent serious case reviews, the report also noted that Louisa’s father had been insufficiently involved in safeguarding enquiries.
“He would have been involved in the handover of care to the mother, and in an ideal position to comment on whether [she] had been drinking or not,” it said. “It is also noteworthy that the father was responsible for making at least two referrals to the police expressing concerns about the mother driving while intoxicated.”
The review recommended both issues be addressed via Dorset’s training offer.
It also said that an unnamed local public protection forum, which the review found had challenged Dorset’s decision to close one of its cases, should be guaranteed a “mechanism to check the progress of single agency actions”.
‘Committed to learning’
In a statement issued by Dorset council, Steve Butler, cabinet member for safeguarding said the council was “committed to learning from this case and working with other agencies to reduce the risk of a similar tragedy happening again”.
“We are never complacent and are focused on improving the way we, and our partners, share and use information to protect children,” Butler said.
He added that Dorset’s introduction of a multi-agency safeguarding hub (MASH) had addressed some of the issues identified by the serious case review, and that midwives were now expected to gather more information relating to women in the early stages of pregnancy.
Sarah Elliott, the independent chair of the Dorset Safeguarding Children Board said the case showed that “key links were not being made” despite the involvement of professionals with Louisa’s family.
“It really does bring home the need for professionals to be curious and share information with one another, so they can consider the whole picture to help keep children safe,” Elliott added.