Critical review reveals chances missed to support family in which father shook baby to death
PUBLISHED: 14:55 15 August 2018 | UPDATED: 10:26 16 August 2018
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A six-month-old baby, shaken to death by her father, was let down by professionals and an under-strain system which should have paid more heed to previous domestic abuse within the family, a review has found.
The father of the girl, known as Child V, was convicted of her manslaughter in December last year and a serious case review has just been published by the Norfolk Safeguarding Children Board.
It reveals a string of occasions over the three years between 2013 and the child’s death in March 2016, when opportunities to put in extra safeguards and support for the Norfolk family - which might have prevented the tragic baby’s terrible fate - were missed.
Social workers, who had been focusing on the family because of concerns about the impact of domestic abuse on the baby’s older brother, were too optimistic that the relationship between the father and the girl’s mother had been patched up.
And a process which was meant to help police, social workers and health visitors share information was not working properly. The report says the multi-agency safeguarding hub at that time, when Norfolk County Council’s children’s service department had been rated inadequate by Oftsed inspectors, was not up to scratch.
And that meant a police notification of a claim of sexual assault allegation, which led to no further action, in 2013 was not shared properly.
That meant health visitors never had a proper record of it and an opportunity of intervention and targeted help was lost.
The report found that the safeguarding hub had been in a state of flux at the time and had been reduced to “simplistic systems and ad hoc information sharing symptomatic of a service under strain”.
After a suicide attempt by the children’s father in 2014, a health visitor noted that he had started to shift responsibility for that attempt on to his partner.
But that was not shared with the social worker, when it should have been, as it was a “significant” sign of “ongoing abuse and coercive control”.
The mother later left the home, but returned soon after in 2014. Despite a social worker’s continued concerns, their team manager “enthusiastically embraced a progressive and proactive approach”, that the couple should get relationship therapy.
The review states that, given the history of violence and abuse, the use of that was “highly questionable” and it was delivered by “an inexperienced and untrained practitioner”. Children’s services ended their intervention in September 2014. In 2015, a daughter was born prematurely and admitted to the neonatal intensive care unit. Staff there were not informed of the domestic abuse history.
The child was allowed home three months later, in November 2015, where the family were supported by the community health service.
But the report says the health visitor had failed to analyse how parental sleep deprivation and the father’s concerns over his job prospects could impact on their ability to parent the child.
It says: “With the benefit of hindsight, it is clear that serious stressors were emerging”.
In February 2016 the little girl was admitted to hospital with a head injury. She was taken to Addenbrooke’s Hospital in Cambridge, but her life support was switched off in March 2, because it was clear she would not recover. Her father was subsequently jailed for manslaughter. The review made a series of recommendations for all the agencies involved to learn from following the tragedy.
They include the need for better sharing of information, an improved understanding of how best to deal with domestic violence and more robust systems to resolve differences of opinion among professionals.
Sara Tough, director of children’s services at Norfolk County Council, said: “V’s death is a tragedy and our sympathies remain with her mother and family.
“Although we were not working with her family during V’s short life, it is clear that the earlier impact of domestic abuse on her sibling was not fully understood by those supporting the family.
“This has been raised in previous reviews and, as a council, we now have a nationally recognised programme to train staff in understanding the signs and impact of domestic violence.”
Sian Larrington, head of service for Norfolk Young People’s Health Services (part of Cambridgeshire Community Services NHS Trust). which provides health visiting services across Norfolk, said: “Our health visitors work incredibly hard to support families and keep children safe on a daily basis and we sincerely apologise that, working alongside partner agencies, we did not meet our own high standards in this tragic case.”
She added: “ We have implemented a range of actions to respond to the review’s multi-agency recommendations. A two day training programme focussing on domestic abuse has been introduced with over 100 practitioners trained across the service. “Named safeguarding lead nurses are available to provide advice, guidance and supervision to practitioners and respond speedily to any concerns identified.
“In addition, we have increased the resources available to support our partnership working with the multi-agency safeguarding hub, including in relation to information sharing and recording.
“We are confident that, having taken on the provision of the health visiting service in October 2015, the developments we have introduced have improved the knowledge, skills and confidence of our practitioners to work proactively with colleagues and families, including when domestic abuse is known to be a factor in a child’s life.”