Social work manager ‘ignored crucial information’ in case where girl suffered life-threatening neglect

Serious case review finds practice failings and lack of challenge led to inaction in months before 'severely malnourished' child admitted to hospital

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An agency social work manager has been heavily criticised by a serious case review, after a neglected five-year-old was admitted to hospital so severely malnourished and dehydrated that professionals believed her life could be at risk.

The review, for Swindon Safeguarding Partnership, uncovered serial failures in local children’s services’ involvement with the girl’s family, including around not acting on ongoing alerts and referrals, not challenging her parents and keeping inadequate records. Other agencies also missed opportunities to share information or escalate concerns at key points.

The assistant team manager handling the case – who should not have been doing so in the first place – “ignored crucial information” and held a “falsely optimistic view of parental motivation and level of cooperation”, the investigation found.

Over the months prior to her hospitalisation in September 2015, the five-year-old, named as ‘Child Q’, and her siblings were stepped down from child protection plans, which had been implemented the previous year because of neglect.

During the period, from December 2014, in which the assistant team manager was in charge of the family’s case, there was no evidence of any direct work with Child Q or her siblings, the review found. This contributed to them being, at times, almost as “invisible” to professionals as they seem to have been to their parents, the review concluded.

The social worker – who declined to engage with the review process – was reported to the Health and Care Professions Council (HCPC). He was suspended for misconduct that “exposed service users to a serious risk of unwarranted harm” at a tribunal in October, because of a two-year failure to record supervisions, as well as for not keeping records in Child Q’s case.

Child Q’s mother and stepfather were jailed in October 2018, for six years and four years and three months respectively, for neglect.

Premature birth

Child Q was born prematurely, weighing just 1kg, in September 2010 and experienced health problems from the outset.

In July 2014, she and her siblings, who were well-known to agencies and already involved with Swindon council under child in need (CIN) procedures, were made subject to children protection plans because of neglect. Issues included the state of their family home, poor school attendance, unexplained injuries and housing and financial problems.

Swindon’s children’s services – then rated ‘requires improvement’, but since judged ‘good’ – have faced longstanding issues around turnover and levels of agency staffing and were restructuring during the period covered by the review.

The assistant team manager, who was being overseen by another temporary manager, “decided to take on” Child Q and her siblings’ case after another social worker left in December 2014, despite it not being accepted practice for a manager to take on a case.

“The [assistant team manager]’s stated intention to allocate to a social worker as soon as possible did not materialise,” the serious case review noted.

In the same month, Child Q was taken to hospital by her mother, who said she had suffered with diarrhoea and vomiting for a week. Despite her being too weak to stand when brought in, doctors discharged her without apparently considering that she was on a child protection plan, and no contact was made with children’s services.

Concerns ignored

In January 2015, a review child protection conference (RCPC) took place at which a newborn sibling of Child Q was also made subject to a plan.

“Ongoing concerns were recorded by [speech and language therapists], [health visitors] and nursery staff regarding child Q’s hunger, non-attendance at nursery and overall condition, during the period January to March,” the serious case review found.

Nonetheless, Child Q and all her siblings were stepped back down to CIN level in March 2015, with their case being closed and referred to family support in August.

No action was taken by children’s services in the wake of an anonymous referral in June reporting serious concerns about Child Q’s wellbeing –which, the review said, the assistant team manager dismissed as “malicious”. This incident formed one allegation in the subsequent HCPC tribunal, though the panel found there was not conclusive proof the assistant team manager had breached safeguarding procedures.

Nor was a promised home visit carried out in September after school staff, concerned by Child Q’s non-attendance, gained access to her home and reported to the assistant team manager that they were “extremely concerned”. Instead, the assistant team manager warned Child Q’s mother by phone that she should take Child Q to school the next day or face child protection procedures.

Days later, Child Q was hospitalised weighing less than 11kg, and was subsequently taken into care.

‘Parents’ views allowed to dominate’

Frontline practitioners, from health and education, interviewed during the investigation acknowledged that Child Q’s large family posed a complex challenge for professionals involved. But they also expressed “significant frustrations” with how the situation – including concerns they raised – was handled by Swindon children’s services.

“Practitioners described the escalation of their concerns following the RCPC in January 2015 and a subsequent meeting with the [assistant team manager] and [their] manager as a significant moment that reinforced their view that the parents’ views were allowed to dominate decisions without sufficient corroboration,” the review said.

Child Q’s parents’ input into the review process appeared to corroborate this picture, with her mother and stepfather praising the assistant team manager as being “like a friend or grandparent” to her children.

As well as a lack of challenge from children’s services, the review found gaping holes in case files relating to Child Q’s family.

No written reports were prepared for RCPCs in January and March 2015 – omissions that, in the latter case, went unchallenged by the conference chair. Nor were records made of core group meetings in early 2015, or CIN meetings between March and August after the children were stepped down.

The environment of general inaction was exacerbated by failures on the part of other agencies, notably health visitors, to escalate concerns. As with children’s services, the review found that health visitors did not keep adequate records, hindering analysis of the development of a strategy to follow up repeated missed appointments with Child Q’s family.

Department ‘a very different place’ now

Responding to the review, a Swindon council spokesperson described the case as “appalling” and said the local authority fully accepted its findings and recommendations, including around child protection procedures, direct work with children and managers holding cases.

“The council’s children’s services department was in a very different place to what it is now when the neglect of Child Q took place four years ago, with soaring numbers of cases, high caseloads and a lack of management oversight, which is well described in the SCR,” the spokesperson said.

Ofsted rated Swindon as requires improvement following an inspection in 2014, but a focused visit last year found that services had declined, with the authority needing to take swift action to improve the identification of risk and management oversight of child protection cases. However, Swindon was rated good earlier this year, after inspectors praised the quality of leadership under director of children’s services, David Haley, in driving practice improvements.

The spokesperson added that many positive points picked up by Ofsted in its summer 2019 inspection had stemmed directly from improvement work undertaken in the wake of the serious case review.

“Since this case we have implemented a neglect framework as well as a training and development programme for staff across agencies so that there is a consistent approach to recognising and responding to neglect,” the spokesperson said. “We will continue to work with our partners to improve our practice and ensure we provide the best possible service to children and families.”

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