Social workers failed to grasp the “complex dynamics” of domestic abuse within a family where the mother subsequently assaulted her baby, causing bleeding on the brain, a serious case review has found.
The investigation by Manchester Safeguarding Partnership concluded that professionals from children’s services and other agencies made persistent assumptions that the father of ‘Child W’ was the only perpetrator of violence within the household, despite evidence to the contrary.
Chances to “holistically assess” the family’s situation were missed, exacerbated by safeguarding partners not being involved in assessments and case conferences. This led to Child W’s child protection plan being inappropriately focused on neglect rather than physical or emotional abuse, the report said.
When a further serious domestic abuse incident between Child W’s parents caused a breach of the plan, the response was not sufficiently robust, the review found.
“This review has evidenced that while there are structures to support an efficient and collaborative response to domestic abuse in Manchester, there were a number of deficits in the timeliness and rigour of interventions with the family,” it concluded. Among a series of recommendations, the review said child protection planning should approach domestic abuse from a “gender-neutral perspective”.
Substance misuse concerns
Child W was admitted to hospital aged four months in November 2018, two months after being placed on a child protection plan with half-siblings ‘S1’ and ‘S2′, who were then aged 10 and seven and who had different fathers.
The family had been known to children’s social care for around four years prior to this, with S1’s school making a referral relating to attendance and home conditions in 2014 that resulted in a professionals’ meeting. Between 2008 and 2012, meanwhile, Child W’s father, ‘WF’, had been convicted of a number of offences, including threatening behaviour, and, in 2017, started receiving support for ADHD, following concerns over his anger management.
Child W’s mother, ‘WM’, had been known to agencies since 2009, both in relation to being a victim of domestic abuse and having been looked after as a young person.
Recent serious case reviews
During 2015 and 2016, several more referrals were made to children’s services about WM, including by S1’s father, who raised concerns about substance misuse, her mental health and an incident in which she and her sister had allegedly attempted to assult him and police officers. In September 2017, the school again contacted children’s services after WM came to collect her children apparently under the influence of alcohol, resulting in an assessment highlighting concerns “regarding WM’s mental health, challenging and violent behaviour and ‘potential’ alcohol and drug use”.
The serious case review noted “particular concern” that a social worker had suggested WM’s behaviour was consistent with amphetamine use but that no further action had been taken, and the case was closed in October 2017. A subsequent “comprehensive and timely” referral by a midwife regarding alcohol use during pregnancy in November 2017 also led to a case that was quickly closed, despite worries about S2’s school attendance and WM’s tendency to “tell different people different stories”.
Soon after Child W was born, in July 2018, a chain of incidents, including of domestic abuse, occurred that, the review found, professionals did not appear to act on.
“There were at least two occasions where WF was distressed and had indicated suicidal ideation,” it said. “This does not appear to have triggered an assessment of the family’s circumstances, and in particular the impact of WF’s presentation and mental health on the children, which, given the history would have been appropriate.”
At the end of the month, Greater Manchester Police informed children’s services of other reports of domestic abuse at Child W’s home, which came in the wake of the apparent breakdown of WM and WF’s relationship. Under police interview, the review noted, WF had denied one of these assaults and had made counter-accusations against WM, including that she had broken his nose earlier in the year.
“Given the previous referral history, the concerns regarding alcohol and cannabis use, WM’s resistant, volatile and challenging behaviours and lack of engagement, the concerns regarding WF’s mental health and the level of domestic abuse already taking place within the family home, this would have been an opportune moment to undertake robust safeguarding enquiries and to holistically assess the family’s circumstances,” the review said.
However the investigation found no evidence of this happening, with section 47 enquiries only being initiated following another serious incident in late August, in which WM sustained bruising after WF allegedly threw stepladders at her.
Despite a social worker visiting Child W’s home and finding WF apparently staying there, the review was not able to confirm that any safety or risk management planning was conducted prior to an initial child protection conference (ICPC) in late September. Two partners with crucial information – the family GP, and WM’s social landlord, One Manchester – were insufficiently involved in the assessment and ICPC, it added.
During this period, the report said, there was already further evidence – including by his having attended A&E – to suggest that WF was not simply the perpetrator of domestic abuse in the household. But factors including WF’s non-attendance at conference, and his “aggressive and challenging” behaviour, reinforced professionals’ “prevailing view” of him, the investigation found.
“Information provided to [the review] suggested that both….the fathers of S2 and S1 were frightened of WM and that this had impacted on dynamics within the family and arrangements regarding contact with the other children,” the report said. “This was not considered as part of the assessment provided to the ICPC and while [S2’s father] was present at conference, in a capacity to support WM, this was an issue that could have benefitted from further exploration.”
In late October, only a fortnight before Child W’s admission to hospital, a further violent domestic incident took place between WM and WF, who was by that time forbidden under the child protection plan from visiting the family home.
But despite four separate referrals being made in relation to this, the emergency duty team was not involved, with an assumption apparently being made that since WF had been taken to hospital, there was no further risk to Child W.
“No consideration took place to ascertain whether further or immediate enquiries were necessary to ensure that Child W or the other children were adequately protected, or what further action was required,” the review said. “This is a critical juncture in Child W’s history and suggests a more robust approach was required at this point.”
In November 2018, paramedics were called to WM’s address after she had reported that Child W was convulsing and not breathing. Medical professionals concluded Child W had suffered subdural bleeding consistent with being shaken without impact. WM subsequently pleaded guilty to assault and was sentenced, in June 2019, to 20 months’ imprisonment.
The review made a number of recommendations including:
- That child in need and child protection planning routinely consider longitudinal family history, including agency involvement and what is known to agencies, and address domestic abuse from a gender-neutral perspective.
- That safety planning is routinely in place between the conclusion of any section 47 enquiry and subsequent ICPC.
- Embedding a trauma-informed approach, particularly where adverse childhood experiences have been identified, as was the case with WM.
- Incorporating motivational interviewing into practice, in particular in tackling parental resistance and non-compliance.
Responding to the serious case review, Dr Henri Giller, independent Chair of the Manchester Safeguarding Partnership said: