A watchdog has told a local authority to review its policies around supervision arrangements, after social workers prevented the parents of a dying baby from spending time with him during his final weeks.
York council became involved with the family, who had not been previously known to children’s services, after the baby, born with a number of health conditions, was found to have unexplained injuries to his ribs.
While these were investigated the parents were barred from spending time with any of their three children unsupervised.
During this time, the baby, ‘Z’, lived out the final two months of his life in a hospital, which told children’s services its staff were unable to facilitate supervision, effectively restricting the parents’ access. But it was up to the local authority to facilitate alternative arrangements, an investigation by the local government and social care ombudsman found.
A court had told York council that supervision arrangements should be kept under review. But the ombudsman said this did not adequately happen – and at no point did a social worker visit Z in hospital.
York council also took nine months longer than it should have to investigate grievances raised by the parents, the ombudsman found.
Michael King, the local government and social care ombudsman, said social workers “should have done more” for the parents at a time when “their world must have felt like it was falling apart”.
York council became involved with the family in 2016 after the father, ‘Mr Y’, took Z to hospital with breathing problems – after which a doctor noticed damage to his ribs on an X-ray.
Mr Y and his partner ‘Ms X’ suggested the injuries could have been caused by previous medical treatment Z had received – an explanation that another doctor cast doubt on.
After a child protection investigation was started, York council drew up a plan setting out that the couple’s other two children must be looked after at home by their grandparents.
Ms X and Mr Y were to be supervised by named relatives during contact with the children, including Z, and were not to have overnight contact with the children at home.
By this time Z had been transferred to another hospital, and the council informed it that the parents should not to spend time with him unless staff were in the room.
The same day, a court granted York council interim care orders while Z’s injuries were investigated. The judge agreed with the council’s safety plan but told the authority to “keep the interim arrangements under review”.
Proposed arrangements at the hospital immediately ran into problems, with social workers being informed repeatedly that staff could not be responsible for supervising Ms X and Mr Y.
This meant family members had to accompany the parents onto the ward, which proved difficult because grandparents were already looking after Z’s siblings.
A second court hearing, 11 days after the first, resulted in the judge being “of the view that any actual harm [to Z] was likely to have been by a stressed parent at worst, not by maliciousness”.
The judge asked the council to consider whether its plan was “sustainable, realistic and right”.
Arrangements with the other two children were relaxed somewhat after this. But with the hospital unable to facilitate supervision, Ms X and Mr Y were still restricted from spending more time with Z even though his condition was worsening.
A social worker contacted the council’s legal department asking for advice on how the situation could be resolved but there was no record of the email being replied to.
At one point shortly before Z’s death, with the baby now in a high dependency unit, Ms X and Mr Y were unable to arrange supervision. The council told the hospital not to allow them to see Z unsupervised and told Mr Y no social worker was available to visit.
It was only in the child’s last hours that the council’s duty team agreed Z needed his mother and so conditions could be relaxed.
In the wake of Z’s death, during the final hearing to consider care orders for Ms X and Mr Y’s other children, the judge criticised York council’s case. The authority withdrew its application for care orders on the second day of the hearing.
“Within proceedings like this, the burden of proof rests firmly on the [council] to establish its case on the balance of probabilities,” the judge is recorded as saying. “There can be no doubt [Z’s] ribs were fractured, but for the sake of clarity, the position which has been reached is that the [council] have decided that those fractures cannot be attributed to parental care.”
Ms X and Mr Y subsequently complained to the council about their family’s treatment – leading to an independent investigation being implemented in late September 2016.
The resulting draft report, completed six months later, found York council at fault on a number of counts.
It found the authority had reviewed the supervision plan in line with the court’s directions. It also said, though, that the council had failed to provide a social worker to supervise a visit, had not told Ms X and Mr Y that one of their other children had been taken for a hospital examination, and had given inadequate advice.
But the council sat on the report while it considered its implications, even after Ms X and Mr Y contacted the ombudsman to complain about the delay. The authority only issued a final adjudication letter agreeing with the investigation findings and setting out remedies in February 2018.
‘No evidence of urgency’
The ombudsman found York council at fault for its handling of the investigation.
“This was a sensitive complaint about issues which had caused Ms X and Mr Y a great deal of distress,” the watchdog’s report said. “There is no evidence in the complaints file that the council recognised this or that any attempts were made to prioritise the complaint even once we became involved.”
Unusually, the ombudsman also revisited some areas of Ms X and Mr Y’s original complaint where the couple were unhappy with York council’s response.
The ombudsman found that, because a social worker failed to visit Z in hospital – claiming she “wasn’t sure it was appropriate given how ill he was” – there had been no assessment of how the baby’s emotional needs were being met.
“As a result of the failure to consider Z’s emotional needs the council failed to properly review supervision arrangements,” the ombudsman said.
York council agreed to the ombudsman’s request that it pay Ms X and Mr Y £2,000, issue apologies, and review policies, including around supervision and its handling of statutory children’s complaints.
Maxine Squire, York’s interim corporate director for children, education and communities, said: “We are extremely sorry for the distress caused and have apologised unreservedly to the family.
“We fully accept the Ombudsman’s findings and recommendations,” she added. “We have already taken action to ensure that lessons are learnt from this case and that our procedures are improved.”