Workforce pressures within Leicester council’s children’s services influenced an “incorrect” decision to end four siblings’ child protection plans, a review into injuries sustained by the youngest child has found.
The move came “despite escalating concerns and increasing non-engagement” by the baby girl’s mother and her partner, the serious case review, one of two published last week by Leicester’s safeguarding children board, found.
Services provided by over-optimistic professionals “mirrored the chaos” the children experienced at home, and failed to protect them, the scathing investigation report said.
A failure to convene a child in need meeting was probably due in part to staff shortages at the council, which received an ‘inadequate’ judgement from Ofsted in March 2015, weeks after the case review was commissioned, the report said. A “mistaken belief that it would not be possible to work with parental resistance” also played a part, it added.
Instead the cases were closed, leaving the baby, named as ‘Nadiya’, and her siblings at continuing risk of harm.
Only after Nadiya was taken to hospital suffering from fractures and brain haemorrhages were the children effectively safeguarded, the review found.
Domestic abuse concerns
Nadiya and her siblings had been known to local child protection services for most of their lives. In 2009 their mother reported to the police that she had been subjected to a forced marriage overseas, while still under 18 years old, and had escaped back to the UK, finding herself pregnant with the eldest child, ‘Adrian’.
She also reported to children’s services soon after Adrian’s birth, claiming that her mother might take the baby away from her. But in both instances she subsequently backtracked on the claims, saying they had been exaggerated to help her get housing.
In 2011, aged 18 and having had a second child, ‘Jana’, the mother began a new relationship with a man, believed to be the father of her third child ‘Mohini’.
“There were significant concerns about the father of Mohini’s violence to Mother,” the review said. “Between December 2011 and March 2013, the police received 14 reports of domestic abuse.”
The new partner was arrested for assault on five occasions, but no convictions were pursued because allegations were repeatedly retracted. During the serious case review process, it was found that Mohini’s father was known to children’s services in his home authority as someone who had been exposed to domestic abuse.
‘Limited attention from professionals’
During a one-year period culminating in Nadiya’s injuries, the review found all four children were taken to hospital with injuries that indicated “either very poor supervision or deliberate abuse”.
“Although the subject of seven child protection conferences and over 30 core group meetings during the period under review, there was not a clear and proactive child protection plan in place,” the review said. “There was no assessment or analysis of the nature of risks facing the children, and mother and the father of Mohini were never challenged about their non–engagement with the very few demands made upon them within the child protection process.”
No comprehensive pre-birth plan was carried out while Nadiya’s mother was pregnant with her new baby, despite known risks and the fact that she was already struggling with her first three children, the review found.
There was an “over-optimism” among some professionals about her ability to cope, and the believe that she loved her children “and this was enough to ensure their wellbeing”,” the review found.
This attitude influenced the decision to end the child protection plans, a move that also led to health visitors reducing their involvement, the review found. Other agencies – some of whom had “continued concerns” – should have done more to challenge the decision, it concluded.
‘Thresholds not understood’
A second serious case review into a similar incident that saw a baby, ‘Robyn’, hospitalised in September 2014, found a series of wider failings within Leicester’s safeguarding structures.
Robyn’s father had also previously been known to social workers because of he and his siblings’ exposure to domestic abuse as children.
Two key episodes – one involving bruising to the baby and one involving the father disclosing mental ill-health and thoughts of harming his mother – should have been escalated by the local ‘front door’ and properly investigated, the review found.
But other professionals, including doctors and other health workers, did too little to explore and refer concerns about Robyn, who was found to have multiple fractures inflicted in at least three separate incidents.
“This case has identified that threshold decisions in the whole are not understood across the [safeguarding] partnership,” the review said. “The case clearly had dimensions of risk and early indicators of harm or potential harm yet did not progress into the child protection arena.”
The twin reviews made a long list of recommendations, including making good-quality legal advice available to social workers, improving neglect assessments and embedding child protection plan audits into practice.
Jenny Myers, independent chair of Leicester’s safeguarding children board, said agencies involved in the reviews had already implemented the changes recommended.
“Since these cases there has been a major overhaul of the LSCB’s policies and procedures, reflecting the need for all partners to work more closely together to identify early on when children are at risk,” she said.
“The guidance on non-accidental injuries in babies, pre-birth assessments and neglect has all been updated, while robust procedures have been put in place to check on the progress of child protection plans,” Myers added.