Social worker turnover probably contributed to drift and missed opportunities in a case where agencies “fundamentally failed to safeguard” three children who faced chronic neglect and sexual abuse, an investigation has found.
A scathing serious case review by Somerset safeguarding children board concluded the children’s parents found it “relatively easy to manipulate” an ineffective network of professionals who had been involved with them for almost 15 years.
Practitioners failed to understand the children’s lived experience or get to grips with their parents’ “resentment and rejection” of their involvement, the report said.
More on child protection
Somerset council’s children’s services were not the only agency found to have suffered from frequent staffing changes during the period covered by the review, which spanned 2012 until 2017.
But the review said social worker turnover at the South West county – which recently voted for early help cuts that a scrutiny board chair warned could harm workforce stability – had probably contributed to damaging “inertia”.
Between 2012 and 2015, the children’s case was overseen by nine different team managers and and six allocated social workers, the investigation found. One of the children, who contributed to the review, said social workers “changed without explanation” and that they could not remember being talked to one-to-one by any social worker who visited their home.
“The ability of professionals from children’s social care to establish effective working relationships with the children and their parents appears to have been hindered due to the number of workers involved with the family,” the review said.
The family at the centre of the serious case review had been known to agencies for a decade prior to 2012 and were described as having struggled to meet the needs of their children “at all ages”.
The investigation concluded that, based on available evidence, neglect experienced by the children was causing them significant harm by the time a child protection case conference was convened in 2012 – and possibly much earlier than that.
The review identified the period immediately following this conference as a crucial missed opportunity, with professionals not carrying out a recommendation from the conference that legal proceedings be pursued if the child protection plan failed.
At the initial conference, a police representative is recorded as having noted that “working with the family would require a strong team of professionals who were able to support each other and stick to agreed plans”.
Instead, the review found, working with the family – who simultaneously displayed “a high level of need and a high level of aggression” – ended up leaving practitioners behaving in a “disempowered and deskilled” manner.
The report suggested staffing problems within children’s services, which often meant no social worker being allocated to the family’s case, may have created a “decision-making vacuum” that impeded information-sharing and allowed things to drift.
But, it said, the failure of agencies to act on the initial child protection plan “could not be explained away” simply by turnover of staff or managers.
Elsewhere the review found procedures had not been properly followed, with children’s services at odds with other agencies – some of whom became “jaded [after] referring concerns to children’s social care, with no apparent effect”.
The child protection plan was stepped down at one point, with records describing a “unanimous” decision despite the school and parent/family support advisors disagreeing with social workers.
“This was clearly an overoptimistic decision, apparently based on assurances from the parents that they would work with professionals under child in need arrangements,” the review said.
The review added that the Signs of Safety practice model, which had recently been introduced in Somerset, did not appear to be being used properly at this stage.
“Signs of Safety is a subtle tool and only works effectively if it begins with an honest multi-agency appraisal of current difficulties [which] does not appear to have happened in this case,” it said.
Concerns aired by a child protection conference chair, meanwhile, appeared to have been too readily dismissed on the basis that they had “no authority over ‘operational’ decisions”.
When the two younger children were eventually made subject to legal proceedings – with their elder sibling having already left home – “significant delay” was caused by lack of organisation on the part of Somerset council.
“Children’s social care also failed to file reports on time and equivocated in the decision whether to seek care orders or supervision orders in respect of the children,” the report said.
The decision to eventually pursue supervision orders – in the face of reservations from Cafcass, the child protection conference chair and even the judge – was described as a second major missed opportunity on behalf of the council.
“Unfortunately, the schedule of expectations proved to be ineffective and did not lead to the hoped-for changes in the parents’ behaviour,” the review said.
“The failure to follow through and return to court if the parents failed to comply has been additionally counter-productive because it demonstrated the local authority’s unwillingness to confront the parents’ lack of cooperation.”
‘Unusual’ sex abuse failures
As well as failures to address neglect, the review said that “an unusual feature of this case [was] that very obvious signs of sexual abuse were not more fully investigated by agencies”.
The youngest of the three children, who had a special educational need, had a history of behaviours that were “strongly indicative” of exposure to sexually abusive behaviour. Some of this was not adequately passed on to children’s services, with safeguarding arrangements at the child’s primary school not compliant with statutory guidance.
One investigation of an allegation, in 2012, was apparently blocked by the mother refusing to allow police to interview the child, while another disclosure of possible abuse, in 2013, was shared with children’s services but never pursued.
“Concerns from the primary school, police intelligence reports and direct experience from the professionals involved with the family needed to be brought together through a section 47 strategy discussion,” the review said – but this did not happen.
The two elder siblings also made disclosures that were not fully investigated at the time, the serious case review said.
One allegation prompted a joint investigation between children’s services and the police that was again discontinued because the family refused to cooperate.
The review also found that an allegation of sexual activity with an adult woman by a male sibling was not correctly considered as a possible case of child sexual exploitation.
“The challenge to all agencies is whether the potential for males to be victims of child sexual exploitation is recognised and responded to with equal seriousness as female victims,” it said.
Among a series of recommendations, the review said Somerset safeguarding children board should develop a comprehensive training programme around neglect, review all agencies’ responses to sexual abuse and ensure support for child protection chairs.
It also recommended additional training for practitioners working with “aggressive and evasive” families, and better auditing of child protection plans.
A statement from the board acknowledged that neglect experienced by the children should have been acted on much sooner and said a number of the serious case review’s recommendations were already being acted upon.
A spokesperson for Somerset council said: “Child protection is a very difficult job, particularly when faced with hostile and evasive families, but the report found a systematic failure to respond adequately and we wholeheartedly apologise for our part in that.
“There will always be more work to do, however, nationally and here in Somerset understanding of neglect and how to respond to it early has improved considerably across all the organisations involved in safeguarding following this case,” the spokesperson added.
The council had now improved training, with more management oversight of cases, and are less reliant on agency staff in the social care workforce with around 90% of team managers now permanent appointments, the spokesperson said.