A lack of oversight caused by frequent changes of social worker led to a toddler suffering significant harm, a case review has found.
The safeguarding practice review found multiple failings by Northamptonshire health and social care professionals in relation to the girl (referred to as Child Au), who suffered chronic neglect and serious injuries during the 17 months she was in her parents’ care.
She had three social workers from September 2018 to January 2019, which meant an assessment took three months to complete and then had to be redone, and there was a lack of management oversight “which resulted in Child Au suffering significant harm”.
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The review also heavily criticised the quality of decision-making by Northamptonshire County Council, saying it was “seriously concerning” that it did not initiate child protection procedures. It also heavily criticised a social worker’s decision not to conduct a home visit immediately when informed of an unexplained injury to Child Au.
Wider failings at ‘inadequate’ council
An inspection of the county council later in 2019, in which it was rated inadequate, suggested Child Au’s experience reflected wider practice failings. Ofsted found children were left for too long on child protection plans when experiencing chronic neglect, with social workers and team managers “over optimistic about change” and accepting self-reporting from carers too readily. Inspectors also criticised management oversight and found longstanding issues with turnover in the council’s “extremely fragile” workforce.
Northamptonshire Children’s Trust, which took control of children’s services from the council in November 2020, apologised for action not being taken sooner to safeguard the child and said there was inadequate support for social workers at the time.
Last year, the toddler’s parents, Sarah Elizabeth Cunnington and Ryan Eames, were both jailed for two years and seven months after pleading guilty to neglecting a child.
Child Au is now being cared for by foster parents and, while the review said she was making progress, it added that she needed specialist intervention to deal with the impact of her early experiences.
Failure to refer
During the first months of Child Au’s life, health visitors noted significant concerns, including in Cunnington’s lack of attachment to Child Au, found the review, commissioned by Northamptonshire Children’s Safeguarding Partnership.
Her eight-month check found she was underweight and developmentally delayed, while in a subsequent visit, in July 2018, a health visitor concluded she was “grossly under stimulated and subject to neglect”.
However, the health visitor did not make a referral to the multi-agency safeguarding hub (MASH), leaving Child Au “at risk of serious neglect and significant harm”, the review found.
When a referral by health visitors was made, at the end of September 2018, the review found that the MASH should have initiated a child protection enquiry as it “indicated that Child Au was being neglected, and that her care was compromised by her parents”.
‘Gravity of risk not recognised’
The team manager’s decision to undertake a single assessment instead “did not recognise the gravity of the risk of harm Child Au was facing”.
After visiting the family, the allocated social worker left the council in early October, meaning the case was passed to a second practitioner.
However, the second social worker did not visit the family until the end of October, did not complete the assessment until December 2018 and then concluded that Child Au should be referred to early help.
The review found this conclusion was “profoundly influenced” by a report from a consultant community paediatrician, who found that Child Au was “well cared for” though “developmentally behind”. The report said this was a “concerning” judgment, based on a single consultation that seemingly did not consider underlying reasons for her presentation, besides medical ones.
Assessment ‘abandoned’
The social care assessment was then effectively “abandoned” when the second social worker left in December 2018, leading the team manager to commission another assessment by a third practitioner.
Shortly before Christmas that year, a housing support officer informed the third social worker that Child Au had been found in her cot, with her arms taped on a bare mattress.
The review said the practitioner should have visited the home immediately instead of waiting until the following day.
The report found that the practitioner did not seemingly raise the issue of the girl’s arms being taped up with the parents on her visit, nor in supervision. The practitioner did find Child Au subdued, with no bedding on her cot, no food for her in the cupboards and no toys visible.
However, despite this, the team manager decided Child Au was in need and she was left with her parents over Christmas, a view challenged by the housing provider.
Lack of action ‘raises serious questions’
“In light of the stark evidence of neglect, the lack of immediate action by children’s social care to initiate child protection procedures raises serious questions of professional judgment,” the review said.
Leaving her in the care of her parents resulted in Child Au suffering injuries, the review found. In early January, the father told the social worker that Child Au had an unexplained swollen arm.
But instead of conducting a home visit and seeking medical advice immediately, she advised him to take the girl to the GP.
The parents did so, but they then waited several hours to take her to A&E, rather than doing so immediately as the doctor advised.
‘Inappropriate and dangerous’
The review found the doctor should have called the social worker to ensure the parents took the child to hospital, with the police summoned if they objected.
“To leave it to the parents to take Child Au, a non-mobile 17-month-old infant, to A&E with an unexplained injury was inappropriate and dangerous,” it found.
Child Au was found to have six fractures, including to her left arm, at different stages of healing and weighed 7.3kg.
The child was taken into police protection and a strategy discussion was held, after which the council applied for an emergency protection order to instigate care proceedings.
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‘Not enough to observe and record neglect’
“If there is one important and resounding lesson to be learned from this review [it] is that it is not enough for professionals to observe and record signs of neglect and abuse,” said the report. “Action is required if children are to be protected from significant harm.”
“Concerns about the care provided by Child Au’s parents were documented within weeks of her birth. It took over a year for those concerns to be referred to children’s social care. It is seriously concerning that once the referral was received, two single assessments did not result in child protection procedures being initiated, nor was the action taken by children’s social care challenged, apart from the housing provider.”
It urged Northamptonshire Safeguarding Children’s Partnership to ensure its neglect strategy learns from the review and there is sufficient professional awareness and understanding of neglect.
‘Support for social workers was inadequate’ – trust
Julian Wooster, chair of Northamptonshire Children’s Trust, said: “This is an incredibly upsetting case, and we owe it to this child to ensure that the learnings from this report are put into practice.
“We apologise that action wasn’t taken earlier to safeguard this child and acknowledge the findings of the report. It is clear, that at the time there was inadequate support and guidance to social workers.
“Good progress has been made to address the recommendations of the report and we are working closely with our partners to ensure every child and young person is given the safest possible environment in which they can flourish. This child is now very settled in foster care and is thriving with support and care.”
The trust is commissioned to provide children’s services by West and North Northamptonshire councils, which replaced the county last year.
An Ofsted monitoring visit covering children in need and those on child protection plans last July found improvements in supervision and that most children received the right level of support. However, inspectors said there were some children for whom neglect was not recognised soon enough, and there was more to do stabilise the workforce.
“Recent Ofsted visits have identified improvements in our services,” said Wooster. “But of course, there is no room for any complacency, and we will continue to work relentlessly to make improvements to our services so that they are true examples of best practice to ensure we achieve the best possible outcomes for children and young people in Northamptonshire.”
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Interesting that it was the lack of social work oversight that lead to the significant harm and not the parents behaviour or parenting of her.? The view and use of language of the report in this sense contributes to the vilification of social workers and in turn directly contributes to the problems in staffing that the report identifies!!! stop it !!
A sad case all round, but the emphasis being put solely onto the Social Work team as usual. How about the Health Visitor who failed to refer adequately or insist on a professionals meeting or the GP who didn’t raise concerns through the correct Chanel. Or the consultant who decided she was being cared for adequately. Or the parents. The comment about the SW telling the parents to take the child to the GP for a check up seems odd, seems appropriate advise to me, obviously if they didn’t take her it may be a different discussion.
And many other services. Nursery or school workers, unfortunately SW ar we not super humans or Gods and I’m pretty sure they are drowning in cases.
You also need to stop defending the indefensible. shocking and appalling practice at every level. This child will suffer the consequences for life.
17 months and was non mobile. That was quite telling to me.
We need to be asking why is there a high turnover of SW’s in LA’s which in turn is causing frequent changes of SW’s & inconsistency for highly vulnerable children/young people & why is there a lack of management support for SW’s & poor management oversight in complex/high risk cases?
This isn’t a unique case though is it? Some other professionals not doing their jobs properly shouldnt be used to absolve social workers for not being proactive. There is another horrendous child death in London about to become public. The poor children are all individuals we should remember them by their names. But the circumstances of social worker missed opportunities are depressingly similar in these reports. Nobody wants to castigate our colleagues because we are all potentially that social worker given the poor leadership under which we practice, but as GW says we can’t always defend the indefensible.
I worked a case where out of hours GP failed to spot broken bone during assessment of young child…. to this day I fail to see why it wasn’t a serious case review
Lots of blame being put onto the social work team- although some clear failings, managerial oversight and multigency responsibility should be more of a theme rather than a buzzword
I agree with you, GW. I know that social workers are, unfortunately frequently vilified and I know how defensive that can make one feel (speaking as a former children’s social worker, with 9 out of 17 years in LA CP/Safeguarding teams). The headline of this article is unfortunate (although true) because it makes it sound like the review placed the ‘blame’ on the shoulders of social workers, which, having read the entire article, does not appear to be the case. As usual in these far too frequent serious case reviews, multiple systemic and professional failings have been identified.
Poor poor overworked social worker. What about the poor child? I’m guessing the social worker didn’t have 6 fractures to their arm and had no means of escape from that torture but them. I’d have more sympathy for the poor poor overworked professionals if you actually saw them standing up to LAs and management about their workloads and budgets instead of blaming the families they are meant to serve for putting too many demands on them. Poor poor social workers. It is hideous how people prioritise protecting colleagues rather than vulnerable people they are meant to protect. There is a widespread culture of delaying and blocking provision to protect budgets, who knows what would have happened if this family had been helped from the start?. There is widespread professional buy in to this culture of blocking and delaying provision. Don’t bash a report that highlights this abuse. Develop a backbone and some ethics and think about who needs the most protection. The vulnerable poor and disabled or the middle class professionals.
I agree with Alycatrow. This should have nothing to do with a ‘turnover of staff’ ‘workloads’, ‘problems at the top with management’. This is about the serious neglect and abuse of a child and the fact that no Professional involved did anything to ensure that child received immediate help. Nothing to do with being super human or godly but about Professionals not doing their job which is to safeguard and protect children from harm.
That’s Not My Job!
This is a story about four people named Everybody, Somebody, Anybody and Nobody.
There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that, because it was Everybody’s job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn’t do it.
It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done.