There are challenges engaging vulnerable young and first-time mothers (and separated fathers) in Universal and Early Help Services and, as a result, the needs of infants and toddlers can be missed, a Serious Case Review into child ‘Ben’ by Croydon Safeguarding Partnership has found.
The SCR also highlighted practice questions about how to engage parents where there are concerns about alleged domestic abuse and the need for assertive enquiry and analysis about men who are known to have a violent history and who form new relationships.
“Ms A, Ben’s Mother, reported adverse childhood experiences, mixed feelings about her pregnancy and low-level depressive symptoms in pregnancy and later. She was offered a range of services because of her vulnerability but did not engage well,” said the report.
“On the occasions that she reported domestic abuse it was taken seriously but she did not then follow through with support, advice or possible actions,” the report added. “Her vulnerability as a young and new mother was recognised after Ben’s birth, it was assessed that they would benefit from the Universal Plus Partnership Health Visiting Pathway.”
“Initially there was good and persistent work to engage with her. This was then impacted by a move and the Universal Plus Pathway approach was disrupted and not re-assessed or re-established,” the report added.
Ben died from significant non-accidental injuries, in October 2019, aged two years and one month. The Croydon Safeguarding Children Partnership commissioned a Rapid Response and agreed that a Safeguarding Practice Review (SPR) should be undertaken. Ben’s mother and her new partner were arrested, and a murder investigation was initiated.
When a child dies, or is seriously harmed, as a result of abuse or neglect, a Serious Case Review is carried out to identify ways that local professionals and organisations can improve the way they work together to safeguard children.
There was an allegation of domestic abuse several months after the move which disrupted the intervention, and a Child and Family Assessment was undertaken where it was decided that a child in need service was not required. It may have been useful to signpost the family back to Early Help Services. Ben and Ms A were again no longer being seen by services.
When Ben was one year and eight months, he had a significant injury to his head and the hospital’s clinical assessments were rigorous and stated that the injury was most likely accidental. However, concerns remained about the cause and further medical investigations were in place. The review has raised the question about the point at which a multi-agency child protection approach to such assessments should be considered when there is doubt about the cause of a significant injury.
Although a referral was made to Children’s Social Care this was not followed through as it was not seen in a child protection context, given the view that the injury was probably accidental. The decision not to proceed with a multi-agency Child and Family Assessment was influenced by the systems context of large numbers of ineffective referrals.
“Opportunities were missed to identify a new male partner who was known to be a potential risk. Ben died from significant injuries, aged two years and one month. His mother and her new partner have been charged with Ben’s murder,” said the report.
Learning from the case included:
The report recommends that there should be serious consideration of routine progression to a Child and Family Assessment for any child with an injury where this is requested by health professionals. When, after a serious unexplained injury, a child requires in-patient observation and/or a skeletal survey there should always be inter-agency dialogue about next steps which would best be achieved through a multi-disciplinary Strategy Discussion.
The Croydon Safeguarding Children Partnership should seek assurance from services and through regular case audits that decisions not to proceed to a referral for any issue are communicated back to the referrer / referral agency in a timely way, with an explanation and an opportunity to question the decision not to accept the referral.
Midwifery, Health Visiting and other services supporting vulnerable pregnant women may wish to consider reviewing how well practitioners are informed about The Family Nurse Partnership Service and how well it is used.
Public Health, with Midwifery, Health Visiting and other relevant services should undertake a review of the current strategy and practice response to parenting education for first time and young parents.
The Croydon Safeguarding Children Partnership should review the wider operation of the arrangements for Early Help provision at Tier 2 of the agreed Threshold Guidance.
The Clinical Commissioning Group should review the guidance to GP Practices on linking Parent and Child records and childcare alerts – such as Was not Brought, child protection enquiries or concerns about possible domestic abuse to ensure that they are cross referenced in the records and the child’s vulnerability is noted on the parent’s record too.
“Ms A’s vulnerability from both her personal history and to alleged domestic abuse was recognised and she was offered services to support her in the early period. However, for reasons which are not fully clear she did not engage with services or dropped out, which was her right. There were no grounds for mandatory intervention. When alleged domestic abuse came to light this led to appropriate responses from the Family Justice Centre, Ms A was given good advice and offered support, but she did not continue with this.”
The recognition by the first Health Visitor that Ms A was vulnerable and required a Universal Plus pathway was good and there was good and persistent work to engage with Ms A as a young mother. A systems dynamic of a move of temporary housing, which was an improvement for Ms A and Ben, meant that the continuity of health visiting was broken. Although assessed as needing an enhanced service this was not followed up by the second health visiting team, which it is understood had staffing difficulties and pressures at the time, the report acknowledged.
“The clinical assessments into Ben’s head injury in May 2019 were rigorous and considered the possibility of non-accidental injury but on balance made a judgement that the injuries were probably accidental; but concerns remained. This raises a question about the point at which a child protection strategy discussion with other key agencies should be considered and whether this should be during the clinical assessment or at the end of the clinical assessment,” said the report.
“The referral from the hospital requesting a social care assessment was lacking in depth about the uncertainty that still remained about the cause of Ben’s injuries. The identity of the male in the household was not established and without being in a formal multi-agency safeguarding framework there was no possibility to complete checks on him that would have revealed a worrying background. These are difficult practice judgement calls which clinicians make all the time and it is clear from this review that the clinicians explored the injuries carefully and also sought specialist advice. It is not practical to say that every consideration of a head injury in a child must result in a Strategy Discussion as many will be accidents but where there are doubts about cause the value of a multi-disciplinary discussion should be considered,” it added.
The decision by children’s social care to overturn the previous decision to undertake an assessment was made in a bigger systems context of the high incidence of referrals being made to social care which were unsuccessful because parents were not fully engaged, had not given consent and there was not a clear threshold for child protection.
The safeguarding system was slowly emerging from being “inadequate” and was more crisis-led and thus seeking to accept only the highest priority referrals. To close the case without informing the hospital was a mistake as this would have led to further dialogue about the hospital’s concerns.
“The police call out in July 2019 when Mr D was identified was not shared with Children’s Services, as it should have been, and given information about Mr D would probably have led to a Child and Family Assessment. This would have identified potential risk to Ben,” the report concluded.
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