On Behalf of the Kent Safeguarding Children Board

CLAIRE

THE EXECUTIVE SUMMARY OF A

SERIOUS CASE REVIEW

On behalf of the Kent Safeguarding Children Board

Serious Case Review Author

Brian Boxall, Independent Consultant

February 2010

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1. INTRODUCTION

1.1  This serious case review is as a result of the death of a 10-week old baby Claire[1]. Her parents found her apparently lifeless in her cot one evening. She was taken to hospital where despite efforts to resuscitate her she was confirmed dead.

1.2  The police were contacted and conducted an investigation. No suspicious circumstances were identified. A subsequent Inquest concluded that Claire died from natural causes due to Sudden Infant Death Syndrome and being small for her age.

1.3  Baby Claire had two siblings, Jane aged 3 years and Tom aged 16 months who lived at the same address. The family was known to Kent Children’s Social Services and to other agencies, but none of the children had ever been subject to a Child Protection Plan.

1.4  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where

(a) abuse or neglect of a child is known or suspected; and

(b) either –

(i) the child has died; or

(ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.

1.5  In view of the nature of the incident, the Kent Serious Case Review Core Group recommended to the Chair of the Kent Safeguarding Children Board (KSCB) that the case met the criteria for a serious case review

1.6 The details of the agencies contributing to the Review are set out at Appendix A. The KSCB constituted a Panel to manage and oversee the conduct of the review. The membership of the Panel is detailed at Appendix B. Mr Richard Green was appointed to produce the Overview Report.

2. KEY FACTS

2.1 Concerns were first raised when the mother was pregnant with her first child, Jane. This resulted in a referral from a midwife. Over the next couple of years there were a number of referrals made to children social services. These were either ‘children in need’ referrals or external reports of abuse, both sexual and physical. None of these referrals were dealt with within the procedural timescales and none were subject to an effective assessment, in line with the [2]Department of Health (DOH) Framework for Assessment.

2.2 All three children experienced at one stage or another faltering growth, also known as ‘Failure to Thrive’. There were a number of occasions when the children should have been referred to the community paediatrician, to consider if the concern was due to organic or non-organic issues. Had this taken place (the last opportunity was just prior to the death of

2.3 Claire) then a plan to address the problem may have increased Claire’s chances of surviving. Advising the use of soya milk for Claire following the suggestion by her mother that she was lactose intolerant was not good practice. A referral to a paediatrician for further investigations should have been made.

2.4 The social worker, when she took over responsibility for the family, started to become proactive in her questioning and probing of the family; this included identification of the sleeping conditions and the challenging of the mother

2.5 The combined health IMR highlights that multi-disciplinary working between GPs, health visitors and community midwives was of a good standard. The referrals from South East Kent Association of Doctors on Call (SEADOC) were also timely. This was supported by the early referral by a community midwife, having identified Claire’s mother to be vulnerable, and the use of the concern and vulnerability liaison form.

2.6 Staffing pressures were identified within children’s social services, and action was taken to ease the pressure, but this was not a timely intervention, and led to inexperienced agency workers, who were under pressure or lacked the appropriate skills, making fundamental mistakes with regard to assessments, recording etc.

2.7. There was a failure to adhere to local safeguarding children procedures for all of the referrals. Supervision within agencies failed to challenge this. A number of local practices were taking place that were not in line with procedures. The local Child Abuse Investigation Unit police officers were not undertaking joint agency visits until children’s social service workers had established proof of injuries. This was compounded by police failure to record contacts with children’s social services as initial strategy discussions or in any form. This meant that the police’s own systems would not highlight concerns, when other officers attended the address for other incidents such as domestic abuse.

2.8 There was/is confusion amongst agencies’ staff as to the exact nature of the contacts between various agencies. Were they involved in strategy discussions, just passing on information, what was their role? This was compounded by the lack of accurate timely recording. Many reported contacts have been identified by one agency but not recorded by another.

2.9 There was contact with the family that should have resulted in information being shared within their own organisation and within the multi agency process. Police failed to share information following domestic disputes and children’s social services failed to share a referral with police, where a criminal offence may have been suspected. Health failed to share concerns about the lodger and when children were presented with injuries.

2.10 The role of the family’s GP practice was pivotal, being the centre of knowledge and record keeping about the family. There was good communications between health professionals identified. However, the family GP appeared to dismiss the concerns about Claire’s mother’s health and the risk she posed to her children, thus reducing the action taken if not the concern.

2.11 The GP also undertook an examination of Jane, following a suggestion that she had been subject to sexual abuse. A paediatrician rather than the GP should have undertaken the examination. Guidance and procedure makes that clear. The failings of the referral process did not help, as children’s social services or police did not advise the GP, and he did not proactively seek advice about any examination. By taking the action he did, the sexual abuse was not fully investigated. This was a mistake in light of the current investigation into possible sexual abuse of Jane.

2.12 The multi agency response to the death of Claire was good and timely. Whilst concerns about the subsequent progress have been raised, the initial response and the support of the family was good

3. CONCLUSIONS AND LEARNING POINTS

3.1 While the death has not been treated as suspicious, the post mortem report linking the death to the ‘faltering growth’ does bring into focus the multi agency dealing with the family for the four years prior to Claire’s death.

3.2 If a referral is not dealt with effectively from the start, in a timely fashion with an appropriate assessment completed correctly, the resultant action is likely to be diluted and the risks to the children may be missed and opportunities to intervene lost. There appear to have been a number of reasons for these shortfalls:

·  The heavy workload of the social workers.

·  Staff vacancies.

·  The social workers’ lack of experience and use of agency social work staff.

·  Lack of effective and proactive supervision.

·  Lack of police response.

·  Lack of challenge from other agencies.

3.3. All agencies need to have in place systems to be able to monitor workloads of individual staff, in order to be able to make early identification of potentially excessive workloads, and to provide some form of intervention.

3.4 Agencies need to ensure there is sufficient proactive supervision available to support staff involved in child protection, especially newly qualified or agency staff. This needs to enable them to challenge their views and perception of what they have been presented with.

3.5 Agencies need to ensure staff working in child protection fully understand procedures, and all other staff are aware of their responsibility and roles in safeguarding children. Professionals, when in discussion with other agencies, need to clearly establish exactly what the status of the contact is, what decisions are made as a result, and to accurately record discussions they have with regard to families.

3.6 Agencies should ensure all staff are aware of their need to safeguard children, including unborn children and of their responsibility to raise concerns in line with safeguarding procedures.

3.7 GPs need to be reminded of their pivotal role in the safeguarding process, especially in local GP practices where they have long standing contacts with families. They also need to be aware of how they should respond to allegations of suspected sexual abuse. There is guidance in national and local procedures.

3.8 A flagging system on GP records for children with ‘faltering growth’ should be explored. This will assist GPs, and other health professionals, to be aware of the concern when a child is presented, and thereby take the appropriate action.

3.9. The mother was able to manipulate the professionals’ response to her and the children. At no time was an assessment into either parent’s ability to care for their children undertaken. Better understanding of their background would have identified patterns of behaviour relevant to the care of their children.

3.10 Core assessments/initial assessments need to be completed in line with Department of Health guidance and include history of parents, in order to be able to assess their parental skills.

3.11 There was significant evidence of neglect, even in the absence of the specific referrals regarding suspected sexual and physical abuse. While there were concerns, there is no evidence that the full extent of the neglect was ever pulled together and acted upon. There is currently no standard tool in place to assist professionals in making an evidence based assessment of level of care.

3.12 An assessment tool should be explored to assist professionals in pulling information together with a view to implementing across the agencies. This issue was highlighted and subject to recommendation in a previous review and is currently being progressed.

3.13 The immediate ‘Rapid Response’ aspect of the local Child Death Review process was good, but once very early assumptions were made that the death was ‘not suspicious,’ it failed to complete an effective investigation, and the role of the rapid response group became confused. It failed to respond to the information supplied that identified that the surviving children were in need of safeguarding. An early section 47 investigation should have taken place, but agencies were confused as to the role of the rapid response group. Children’s social services should have intervened and progressed the case to a strategy discussion.

3.14 The current procedures need to be reviewed to ensure clarity regarding roles and functions, and the need to safeguard any surviving children. Agencies must ensure that their staff are aware of the role of the Child Death Review process. This issue was identified in the ‘Billy ‘review and was subject to recommendations.

3.15. Police should review the use of the word ‘non suspicious’ in the case of a baby/child death. The use of an expression such as ‘unexplained’ should be considered until the exact circumstances of the death are known and evidenced.

3.16 There are a number of areas of concern in this review replicated in the ‘Billy’ serious case review. The common themes should be pulled together and addressed as a priority. These include:

·  Staff working under pressure.

·  Confusion with regard to the Child Death Review Process.

·  The effect on the child death review process once police have reached a no crime conclusion.

3.17 During the involvement with this family agencies had important information that was never combined into a coherent picture. This may have enabled safeguarding issues to be identified and acted upon at an earlier stage. Having acknowledged this, the panel did not believe the evidence was such that even if all the information had been shared, it would have enabled the removal of the children from the parents or prevented Claire’s death.

4. RECOMMENDATIONS FROM THE OVERVIEW REPORT

4.1 Many of the areas of concern highlighted have been addressed by the agencies involved in their Internal Management Reviews (IMR) and action plans. Others, such as a review of the Child Death Review Process and the assessment tool to assist the identification of neglect, form part of the recommendations in previous reviews. The following are additional recommendations for the attention of the Kent Safeguarding Children Board (KSCB), and in some cases for individual or joint agency action.

4.2 All Agencies

4.2.1 All agencies to be fully cognisant of any areas of pressure that may affect their ability to safeguard children i.e. staffing levels, workloads, and the provision of supervision, and have in place systems to address any concerns

4.2.2 All staff need to be made aware of their responsibility to keep accurate records which reflect decision making. Records involving such decision-making should be circulated in a timely fashion.