Serious case review criticises ‘overwhelmed’ social workers’ record-keeping

Coventry council practitioners failed to disclose full information and showed 'professional preciousness', investigation finds


Social workers at a struggling West Midlands council felt “overwhelmed” by their caseloads and failed to keep proper records, a serious case review into a life-changing head injury sustained by an infant has found.

The review found no evidence that any professional could have foreseen or prevented the harm to the baby, Child F, which occurred in Coventry during September 2015 and is still being looked into by West Midlands police.

But the investigation’s scope also included the parenting of Child F’s older half-siblings – in particular Child V, who was eight in 2012, the start of the period covered by the review – and work carried out by agencies to support this.

Coventry council children’s services, rated ‘inadequate’ in January 2014 by Ofsted, was involved on and off with the family from 2008, and the review highlighted a number of practice concerns.

These included “poor quality and inconsistent” record-keeping, failing to produce proper chronologies and inadequate information sharing. The review also identified “professional preciousness”, which meant non-statutory organisations were at times shut out from ongoing practice.

Weight concerns

Child V first became known to social workers after being admitted to hospital in July 2008 due to not gaining weight.

The hospital contacted Coventry council’s referral and assessment team (RAS), resulting in an agreement that a further referral to children’s social would be made if health visitor appointments were missed or Child V lost weight, however Child V made good progress and was discharged from paediatric follow-up in March 2009.

On 16 May 2013, a family support worker based at Child V’s school made a referral to children’s services. The child’s father, who was no longer with the mother, reported he had seen bruises, which he thought were fingermarks on his child’s arm, during a contact visit.

When a social worker in the RAS – who was “very new” and in her first post – visited Child V’s home, she found the child was made to sleep on a urine-soaked mattress, while the eldest sibling Child G had a “lovely made-up bed”. No bruises were however observed.

Lack of engagement

Over the next few months an initial assessment was carried out, at first resulting in no further action, before the case was escalated to child in need level in September 2013.

During this period there was some conflict between the family support worker, who was unhappy at being told to stop working with the family, and the social worker. The mother preferred to confide in the family support worker, and disclosed that her relationship with Child V’s father had been abusive.

At one stage, in June, the school made another referral because of a lack of engagement between children’s services and the family – though the social worker did eventually build a rapport with Child V.

In October 2013 the school made further referrals, which apparently “were investigated and appeared to have no substance”, though the case sat open in the RAS.

“Children’s social care (CSC) reported that it is difficult from the records to determine the perceived level of concern about Child V and whether or how that perception changed, or whether it simply drifted,” the review said.

‘Very poor’ records

In its submission to the serious case review, Coventry council acknowledged that record-keeping within the service during the review period had generally been “very poor”, making it impossible to retrospectively trace Child V’s progress. The council added that “neither the voice of Child V, nor that of Child G”, were evident from records.

In relation to the 16 May report of bruising to Child V, this was not mentioned in a referral made by children’s services to the police. This omission possibly prevented a joint visit being suggested by the police in the wake of a second May referral, regarding an injury of uncertain cause to Child V’s hand.

During the months until April 2014, while Child V remained on a child in need (CiN) plan, CiN meetings took place but were not logged on children’s services’ records, nor were any minutes circulated to her school. A supervision note recorded bruising to Child V’s face in November 2013, but there was no evidence of subsequent contact by a social worker either with the child or her parents.

“The school’s view was that there was still work to do with this family and yet there had been no information or handover for them,” the review said. “Inter-agency working between CSC and the school appears to have been weak during this period.”

But it added that, during this time, the RAS team was swamped with cases – 30 to 50 per worker – which was making them near-impossible to progress.

‘Inadequate’ response

In late January 2015, Child F’s mother booked for antenatal care after becoming pregnant, attending with her new partner, the baby’s father. She was described by a midwife as being “quite open and honest” about previous social services involvement, resulting in a request for further information from the hospital.

This was received by a social worker in Coventry’s multi-agency safeguarding hub (MASH), who provided a “limited and inaccurate” response, saying that children’s services’ last involvement had been in May 2013. The review suggested that the social worker may not have looked at the full case notes, but also pointed out that the lack of a proper chronology would have hindered the observation of a pattern of events that could raise alarms with regard to the new baby.

The following month a midwife made further contact with the RAS team, but was unable to speak with the social worker formerly involved with the family since the case was deemed closed.

“Health and educational professionals interviewed have expressed frustration at the lack of access to the case social worker if a case has been closed, and therefore feel they are not able to get sufficient relevant information on their client,” the review said.

‘Reaffirm child’s voice’

Among a series of recommendations the review said Coventry’s children’s services – now rated ‘requires improvement’ – must refresh its guidance on record-keeping. It also told the council to reaffirm the voice of the child and improve its approach to information sharing.

A spokesman for Coventry council said: “Every day more than 300 social workers are out working with children and families across Coventry making incredibly difficult decisions – that is why we place a huge focus in Coventry on continued learning and challenging ourselves to make sure our staff are up to date with the very best practice.”

The spokesman said that the review’s recommendations would “of course” become part of that learning.

“We note concerns raised in the review about poor note-keeping and record sharing,” the spokesman added. “This is an area that has improved significantly in recent years, most notably with the introduction of the multi-agency safeguarding hub, which has allowed agencies involved in the protection of children to work much more closely together.”

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4 Responses to Serious case review criticises ‘overwhelmed’ social workers’ record-keeping

  1. Anonymous September 11, 2018 at 5:29 pm #

    Another increadible loss of a precious child. As SWs continue being swamped with cases a child is missed and as a result losses his battle. It is so disheartening to read these losses and this really makes me question my willingness to continue in this work. It is frustrating and deeply upsetting to hear another death.

    • angela gadsdon September 12, 2018 at 1:18 pm #

      What is not clear from the resume is what other agencies did apart from passing issue to CSC. Issue in withdrawing family worker probably due to reduction in family support services and not just action of SW SW do not have the authority to make such independent decisions, only recommendations, management make these decisions.clear need for joint agency responsibility for a child and a system of joint agency review if any agency believes a child is mot properly cared for and not wait for a tragedy to occur.

  2. Tom J September 12, 2018 at 11:23 am #

    ”team was swamped with cases – 30 to 50 per worker”

    How many deaths and how many serious case reviews do we need before local authorities seriously address this?

    Biggest failure of Laming and Munro was that they did not suggest a cap similar to how we have with class sizes.

  3. sw111 September 14, 2018 at 1:29 pm #

    Again the failure of the local authority and systemic dysfunction.
    Sad, very sad.
    Management take responsibility for the lapses and donor blame the workers like hcpc.