Opportunities were missed to protect six vulnerable children who were seriously hurt by their parents, with not enough focus on the dangers posed by domestic abuse, a review has found.
Three family members are in prison - with one having shaken their six-month-old daughter to death - and criminal investigations are continuing in three more cases.
And watchdogs have said that chances were missed to provide better safeguarding to the Norfolk children, whose ages range from three months to three years.
In all the cases, the relationship between the parents featured conflict and, in four of them, there was evidence of domestic abuse.
But the review by the Norfolk Safeguarding Children Partnership found questions about the presence of such abuse were "rarely asked" - against existing guidance and protocol.
There was also information to suggest that, in five of the cases, at least one of the parents had experienced neglect or abuse in childhood or significant family difficulties in their teenage years.
The review said there was "little understanding" about what that mean in terms of parental needs and capacity to look after their own children.
Three of the cases had already been the subject of serious case reviews by the independent partnership.
But those cases, which also included a nine-month-old who suffered a fractured skull and arm while in the care of their father, plus a three year-old who suffered a serious head injury at the hands of her mother's partner, have been reviewed as part of a wider look at what went wrong.
Two new cases - and a sixth case which would not normally have met the criteria for a serious case review - have also been examined as part of the partnership's 'thematic' case review.
In one of the new cases, which happened in December 2016, a child who was just under two-years-old, was taken to hospital with extensive injuries, including a life-threatening head injury.
The mother and boyfriend of that child, known as child AF1 in the review, are subject of criminal investigations.
A seven-month-old child, known as child AF2 went to hospital in November 2017 with at least 15 fractures and multiple bleeds on the brain.
Her mother and partner were arrested and the child was put into foster care.
The sixth case, known as child AF3 was only three months old and had suffered a chronic brain injury. They were found to have a previous skull fracture and a serious condition where a head injury meant blood had collected between the skull and the surface of the brain.
In the case of child AF1, had questions about domestic abuse and the mother's own childhood been asked, then health visitors would have been able to build a better relationship and establish the mother's capacity for parenting, the report said.
In four of the cases, the mother experienced a stressful birth, with one mother describing her child's birth as "sad and scary".
In four cases, there were difficulties in feeding in the early months.
And in all of the cases, at critical points there was "little evidence" of good decision making by various organisations, such as social workers, health visitors and police.
In four of the cases, the use of cannabis or alcohol by parents impacted on the child.
David Ashcroft, independent chairman of the partnership, said: "This report looks at the serious injuries inflicted on six small children.
"It makes for difficult and sad reading and, as a partnership, we want to do all we can to prevent abuse of any kind to any child.
"This review has given us a really useful insight into what supports good practice. We all need to be alert to the indications where parents may need extra help in keeping small children safe, and to minimise the risks they may face.
"Much of the learning identified in this review is not exclusive to Norfolk and there is no magic wand, in the form of a series of recommendations, that provide an easy answer."
The review makes two recommendations - one for a multi-agency task force to be "urgently" formed in Norfolk, to help keep such at-risk children safe.
Representatives from the front-line will collate data on serious injuries to young children, with the task force overseeing practice and getting a better understanding the extent of the issue.
The Norfolk Safeguarding Children's Board is also urged to build on the work completed during the review and for all organisations to learn from it.
Key findings
These are among the key findings of the review:
- More recognition needed into impact of adverse childhood experiences on parents and how that affects how they treat their children
- Multi-agency risk assessments must be strengthened with respectful relationships, along with improved ownership of risk and better decision-making
- Frontline workers should ensure they know hot spots in their caseload and prioritise accordingly - challenging managers, colleagues and political leaders
- Greater appreciation is needed that safeguarding children is a human service and the emotional impact of the work on the workforce has a bearing on how children are safeguarded
- The multi-agency safeguarding workforce is a precious resource and its value and examples of good practice should be celebrated and promoted
- Needs to be more energy and commitment to build partnership working.
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