A “gap in the knowledge and understanding of culture and beliefs” within Traveller communities fuelled an ineffective social work response to the neglect of a young child subsequently found to be malnourished, a serious case review has found.
The review found a fear of Traveller communities among professionals involved with the family of the child, ‘AG’, and said they had downplayed concerns around domestic abuse and become focused on recording, rather than analysing their circumstances.
Children’s services had “no awareness” of potential problems around assigning a male social worker to AG’s mother and her children, given sensitivities relating to women being in the company of men not from their family, it added.
“This is of concern and needs to be addressed urgently,” the review said.
The case review was one of a pair by the same author published last month by the Norfolk Safeguarding Children Partnership. The second concerned a five-year-old, ‘AI’ who sustained severe burns to 26% of her body after playing unsupervised with a cigarette lighter.
Both reviews explored evidence that professionals working in the deprived east of the county, who were working under high pressure and with significant shortages, had become desensitised to the conditions in which neglected children were living. AG’s case had recently been stepped down from child protection to child in need, while two days before the incident that triggered the review, AI’s had been recommended to be stepped down to early help.
The two investigations also raised questions around children’s services’ appreciation of and responses to parental learning difficulties or disabilities.
Chris Robson, the chair of Norfolk Safeguarding Children Partnership, said there was “much to learn” from the cases and that the body was now working on a new strategy to improve its response to neglect.
In September 2018, AG was found to be severely malnourished, after attending hospital for a child protection medical agreed on at the same time as a decision was made to step down his and his siblings’ child protection plans. A subsequent X-ray revealed a number of fractures to his upper arm, at which point AG and his five siblings were placed with foster carers.
The family had been referred to children’s services in November 2017 by the police and workers in a women’s refuge where AG and his siblings had been living after their mother reported fleeing abuse from their father. This followed on from an unsuccessful homelessness application, which included their father, made on the basis that they had been forced to leave their previous home due to harassment relating to their Traveller background.
Recent serious case reviews
The children were made subject to child protection plans under the category of neglect. Not long afterwards, in February 2018, they and their mother left the refuge and went to live with their father on a Traveller site.
The review found that the child protection plan was originally “realistic” in meeting the children’s needs, including around parenting and supervision, attending medical appointments and supporting the family to obtain secure housing. But over the coming months, professionals lost their focus on the inadequate and overcrowded conditions the children were living in.
“[They] appear to have been desensitised to the ongoing and chronic neglect of the children and the concerning weight loss of AG,” the report said.
On the latter factor, the review found children’s services appeared to have been too reassured by a paediatrician who did not raise alarms after examining AG, despite describing the boy as “sick and weak”. This led to friction with a midwife who continued to voice concerns that AG was malnourished.
Domestic abuse ‘minimised’
The report also noted that professionals either “seemed to accept” an explanation by the parents that they had invented the domestic abuse as a means of securing accommodation, or seemed to “minimise” the allegation.
“[They] lost sight of the violence that had been reported and became focused on the housing situation; the view being that if the family had secure and appropriate housing then ‘everything would be alright’,” the review said. The SCR found that this was possibly down to an “unconscious bias of cultural norms” from social workers and others”.
It found too the multi-agency network had failed to get to grips with the learning and literacy difficulties of the parents, who struggled to fully comprehend concerns that were often set out in written form.
The investigation suggested that the ineffective implementation of the child protection plan was linked to a lack of confidence dealing with people from Traveller communities.
But it also criticised conditions prevalent at the time within local children’s services, which were co-located with health colleagues. While frequent case discussions and supervisions did take place, the review found the ad-hoc, unstructured and sometimes undocumented nature of these undermined their effectiveness.
‘Problematic multi-agency working’
The report into child AI, which was carried out under the new children safeguarding practice review (CSPR) arrangements, also highlighted difficult working conditions for social work and health colleagues in the same locality.
“The reputation of the area makes it difficult to recruit and the focus had been on recruiting rather than thinking about the effectiveness of how the services were working together,” it said. “Problematic multi-agency working can result in lost opportunities for protecting children from harm.”
AI’s injuries were sustained in August 2019, soon after a decision had been taken to step down her case – which had been subject to a child protection plan during 2018 – from child in need to early help services. Eighteen months previously, ambulances had been called to the flat she shared with her mother on two other occasions after AI had accidents causing burns and bruises.
Police and housing officers were also called to to the property due to concerns over antisocial behaviour and possible child sexual exploitation taking place there. An initial child protection conference (IPCC) was convened in April 2018 due to these and the state of the home, leading to a neglect-category plan being put in place for AI.
In late summer 2018, with professionals continuing to be concerned about the mother’s ability to parent safely, another IPCC was held in relation to a new baby she was carrying, with the decision made to place the infant on a child in need plan after birth. Soon afterwards, at a review child protection conference professionals unanimously decided to step down AI’s plan to child in need, based on an assessment that risks had reduced, with a view to handing it over to early help.
No consideration of capcity to make changes
The review observed that after the case had been stepped down, AI had some unexplained bruises and was also reported to be hitting other children at the school where she had started. Nonetheless, the case was closed and handed to early help.
Before this took place, the review found, a meeting involving the wider family network should have been held but this did not happen.
Over the winter, AI’s mother suffered with low mood, anxiety and depression, and conditions in the home deteriorated. Social workers again became involved in spring 2019, after police visited and found the place in a poor condition and AI’s mother and her brother “very drowsy”, but the case was again passed to early help.
The review noted that while social workers had provided clear assessments of what needed to change for AI and hew new sibling, there was no apparent consideration of whether she had capacity to make these changes.
It concluded that a planned referral to adult learning disability services – which was never made – was unlikely to have led to support. But following the incident in which AI was badly burned, a psychological assessment identified that the mother found it hard to process complex verbal information, and a subsequent residential family placement broke down because of her struggles to to keep her children safe.
“It is evident the professionals working with the mother never fully understood the possible implications and limitations of how successfully [she] was able to parent and keep her children safe on a daily basis,” the review said.
‘Neglect is a particularly difficult area’
Responding to the two reviews, Norfolk Safeguarding Children Partnership chair Chris Robson said: “Neglect is a particularly difficult area because everyone has a different perception of what it is and when to intervene. Professionals want to build on family’s strengths and give them opportunities to make positive changes for their children, recognising that there is a lasting impact on children when they are removed from their families and come into care.”
He added: “As a partnership, making further improvements to how we identify, prevent and tackle neglect is one of our top priorities and we are working on a new strategy to further strengthen practice. There is no doubt that the current pandemic has increased pressure on families, which means it is more important than ever we are all alive to the signs and risks of neglect – not just professionals but families and communities.