Workforce pressures to blame for ‘chaotic’ social work failures to protect baby, review finds

Investigation in Leicester finds capacity issues, over-optimism and lack of challenge led to child protection plans being prematurely ended

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The failure to review the woman's care plan led indirectly to the woman’s care package ending, leaving her without support for more than six months, which was a “serious injustice”.

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.”

‘Major overhaul’

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.

11 Responses to Workforce pressures to blame for ‘chaotic’ social work failures to protect baby, review finds

  1. Andy Foster April 3, 2019 at 7:54 pm #

    Excuse me….are we not in a new age of accountability? This is a mealy-mouthed fudge of extravagant proportions. Workforce pressures are not responsible for decision-making. Mature, learned, qualified adults are responsible for decision-making in this realm. We cannot hold a ‘context’ responsible for the failures that compromise childrens’ safety.

    • Tom J April 4, 2019 at 9:57 am #

      Andy- workforce pressures affect decision making every single day.

      Many social workers have poor or no supervision, constant changes of team managers, so many cases they have under 30 minutes a week to look at a case, limited resources, so much paperwork that reflection comes last.

      This is not to say that there is no accountability for decisions, but the context clearly does matter.

      • Andy Foster April 4, 2019 at 10:52 pm #

        Tom J……..a shame and a tad disconcerting that you did not read/understand my comment. At no point did I suggest or say that the context does not matter. Of course it does. However, ultimately the adults are accountable as it is they and they alone who make the decisions. Nothing more, nothing less. In the future, please do not imply that I have made a particular point when I categorically have not. I do hope that your assessments are somewhat more exacting and that they reflect your observations evidentially and rather more accurately than you have intoned in this instance.

        • Tom J April 5, 2019 at 10:05 am #

          Andy- but they do not make those decisions in a vacuum. If a child on my caseload is harmed tonight, of course I must hold some accountability in terms of what I did and what I knew, however you seem to be applying that I and the other professionals would be more accountable than the parent/person who harms the child?

          • Andy Foster April 5, 2019 at 6:24 pm #

            Tom J – I am not quite sure whether you are being obtuse or whether you have too much time on your hands that you are spending on trying to ‘wind me up’.
            Yes, of course, decisions are not made in a vacuum. No, I am not applying (sic) or rather I am not implying some king of accountability hierarchy. I am not seeking to separate out accountability in terms of proportions. Abusers of course are accountable for their actions. I have been attempting to discuss the broader notion of ‘accountability as it applies to us all.

            My point is simple. Practitioners, managers and others are charged with the duty to safeguard children. These professionals are recruited, selected and ultimately are accountable for what they do, how they do it and when they do it. That is the examination paper and that is the job. Nothing more, nothing less. My response is concerned only with making that point.

            Accountability, as a mature concept, is best understood when the actions/inactions of relevant professionals are considered evidentially, robustly and with absolute care and attention. Accountability per se is not designed to be an instrument of blame and nor should it ever be used in that manner. We are accountable for the things we do that may not be successful and we are also accountable for the things we do that demonstrate the excellence of the profession’s contribution. This positive aspect is typically and unfortunately ignored by many, particularly those who bang on relentlessly about the inadequacies of so-called ‘management’, copious paperwork, increasingly smaller budget allocations and fewer resources. I think we all know that reality and that debate sits elsewhere………and before you suggest otherwise, no, I do not dispute that context! However, the context does not ‘make’ individuals behave or practice in a specific fashion. If we sadly believe that this is the case, I suggest revisiting the allied principles of personal responsibility and personal authenticity. Alternatively, you can of course choose to be a ‘victim’.

  2. Disillusioned April 4, 2019 at 11:59 am #

    To shift the blame from management and their poor decision making, contextual factors are flagged. However, when it is the social worker’s lapses, accountability is the dwelt upon and the social worker is sacked and referred to HCPC.
    Such sheer inconsistency is deplorable.
    Accountability should be expected from the management also – they don’t lose their job. Instead they are protected.

  3. Nadine April 5, 2019 at 12:52 am #

    I understand fully as an AMHP working in a London borough with management that are not replacing staff but expecting the same work and no time to write up reports,working at dangerous levels and cutting beds.
    Management do not seem bothered as long as they meet targets.

  4. steppity April 5, 2019 at 9:06 am #

    Major overhaul on policies and procedures and updated guidance. Absolute Tosh, With more oversight on CP plans. In other words escalate concerns about social work practice. Not a mention of how they will address reducing case loads, having affective supervisions, and social workers actually having the bloody time to keep these children safe.

  5. Kolla April 6, 2019 at 12:50 am #

    Seriously being overworked as a social worker cannot be an excuse this case should have been escalated to legal planning meeting due to number of concerns and lack of engagement from parents. De-registration from CP plan should not have happened however all involved professionals are responsible for that smacks of poor practice and lack of professional curiosity to me

  6. Helen April 12, 2019 at 8:01 pm #

    This is going to be more and more common. Policies and procedures don’t protect children when those tasked with doing so don’t have time to spend with those children. It’s always the same response from management. Policies and procedures have been updated. This generally means another piece of paperwork to fill out. How about getting more staff, treating them well, ensuring they have both clinical supervision and case management supervision, and ensuring managers treat their staff with respect.

  7. Sarah April 24, 2019 at 5:13 pm #

    As a person who has been in social work for 28 years now, in various roles, I agree with those who highlight “Churn” as a real danger to children. Effective social work requires an emotional investment from the worker, which leads to a commitment to a conscientious application of attention to the case.

    When people are employed on a temporary basis, or are made to feel they are just part of a “business” they are much less likely to invest in the children and their families emotionally or in the team of workers trying to deliver a service.

    I have seen some shocking practice where people have ticked boxes in data systems to make it look like they have place a recording of important material, but the box is blank. These workers probably would like to provide a good quality report of their work, but they are often told they are leaving by the end of the week (agency workers given short notice). Managers think they have saved a buck, but in reality they have upset workers, impoverished information systems and team work and worst of all put children at risk.
    where work is relationship based there is a need for long term investment in teams and training and nurturing of staff, also a recognition of the impact of dealing with harrowing material month on month, with good quality clinical supervision available.