Staff churn caused ‘organisational memory loss’ in case where baby was blinded in one eye, review finds

Turnover of both social workers and managers in Cumbria meant risks to infant were never adequately explored, investigation concludes

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Workforce churn at a county’s children’s services triggered ‘organisational memory loss’ that meant risk to a baby, later blinded in one eye by his father, was never properly explored, a serious case review has found.

The review by Cumbria’s local safeguarding children board (LSCB) found four social workers were involved in quick succession with the family of the six-month-old, named as ‘Child BE’.

Patchy assessments and handovers between practitioners, complicated by “unprecedented” changes among managers supervising them, led to poor information sharing with other agencies and to a focus on Child BE’s siblings, the investigation revealed.

Cumbria council was judged ‘inadequate’ by Ofsted shortly before the period in 2015 and 2016 covered by the review, with vacancies and agency worker numbers rising significantly and sickness rates hitting twice the national average.

Child BE was taken into hospital in September 2016 with an eye injury, with fractures to his ribs also identified.

His father, who had a “long and complex” history of domestic abuse, was subsequently convicted of causing grievous bodily harm and sentenced to four years’ imprisonment, with the proceedings delaying the serious case review’s publication.

‘Further exploration needed’

The serious case review said Child BE had been known to Cumbria children’s services since before his birth, with concerns initially raised by another local authority in relation to a medical examination of a sibling.

Child BE’s half-sister had been on a child in need plan owing to domestic abuse within the family. His father, who had longstanding issues with mental health, substance misuse and violence within relationships, was also alleged to have previously harmed a five-week-old.

In late 2015, an ex-partner of Child BE’s father told Cumbria council’s children’s services that he and Child BE’s mother – then six months’ pregnant with the baby – had intimidated her, including by smashing a car window.

While Child BE and his half-siblings were made subject to child in need plans, short-staffing over Christmas meant risks to the unborn baby were not fully explored while the case was within Cumbria’s safeguarding hub.

The social worker who first took on the case over the Christmas period “felt she had given less priority to a certain element of the assessment as a result of time constraints”, the review said. “She knew and expected that this area (risk to Child BE) would need further exploration going forward.”

‘Agencies operated unaware’

But such investigations did not take place, the review found, with health visitors and midwives not kept informed as to Child BE’s status nor invited to meetings before and after his birth in March 2016.

“In the case of the first meeting this was an oversight, but staff turnover and inadequate recording have resulted in children’s social care being unable to confirm the reason in relation to meetings that followed,” the review said. “Agencies operated unaware of Child BE’s CIN status throughout the scoping period.”

An agency social worker who was allocated the case left at short notice without conducting a proper handover, with calls from other professionals relating to child BE going unreturned.

When another practitioner then became involved they took “an early view that Child BE no longer met the threshold for a child in need plan,” the review found.

“This can only be explained by considering that [they were] the third in three months, and the situation regarding management oversight exacerbated the organisational loss of memory.”

‘Missed opportunity’

Subsequent child in need meetings, which continued to exclude health professionals, saw children’s services focus on the parents’ preferred agenda of custody arrangements for Child BE’s elder half-siblings.

Neither family history relating to violence, nor Child BE’s father’s involvement with mental health services, were adequately considered. Child BE’s and his half-sister’s cases were closed in August 2016.

A few weeks later – the day before the injury to Child BE’s eye – social workers visited the infant’s home and were told by his half-brother that he wanted to leave because of aggression by their father.

But despite the older boy detailing both verbal threats and “being grabbed by the scruff of the neck”, no record of a follow-up discussion with a between the social workers and a manager took place.

“BE and his half-sister remained in the household with no further assessment being undertaken,” the review said. “It is unlikely this missed opportunity could have arisen with consistent management oversight.”

Risks ‘lost’

The serious case review concluded that the shortcomings in care experienced by Child BE had been set in motion from the beginning of the children’s services assessment process but had been exacerbated by staff changes.

Along the way risks to Child BE were “lost”, the report said, adding that while his parents cooperated with the child in need plan, their parenting was never assessed. “Child in need planning failed to have any tangible, positive impact for Child BE throughout the scoping period of this review,” it observed.

The review noted similarities – in terms of issues with assessments and planning, multi-agency working and failing to consider all adults in a home – with two earlier investigations, into the cases of ‘Child L’ and ‘Child O’. It made several recommendations, including around processes to support child in need planning, the impact of managerial absences and the need for greater professional curiosity.

John Macilwraith, executive director of people at Cumbria council, responded to the report by saying it was clear assessing risk and partnership working “should have been better”.

“Since the events described in the report we have reviewed and made significant changes to how we handle and process any incoming safeguarding referrals and conduct assessments, ensuring children consistently receive a timely and multi-agency coordinated response to their needs. We have also worked hard to improve the recruitment and retention of social workers to ensure consistency of service. These improvements have been recognised by Ofsted and the Department for Education,” Macilwraith said.

A statement issued by Gill Rigg, the chair of Cumbria LSCB, said that because of the time-lag in the review’s publication – as a result of legal proceedings – a “considerable amount” of work had already been done to address the shortcomings identified.

“The work to implement the recommendations and to monitor their impact on practice will become part of the long term work of the LSCB and member agencies,” she added.

For more information, see the LSCB’s response to the SCR.

One Response to Staff churn caused ‘organisational memory loss’ in case where baby was blinded in one eye, review finds

  1. martin July 20, 2019 at 11:58 pm #

    This is a further example of negligent practice which has to stop. Managerial oversight seemed very lax and this was instrumental in the recommendations not being either adhered to or acted upon.

    Shameful, to think that those in our profession are not keen or anle to see safeguarding measures through.