Tonight sees the first Full Council meeting since two Serious Case Reviews were published by the IW Safeguarding Children Board.
The Serious Case review of the case of Baby X showed significant failings of Isle of Wight Children’s Services – judged by Ofsted in January as inadequate. Unfortunately the pattern of failings is also reflected in the details of Baby T’s case.
Baby T admitted to hospital
The Serious Case Review (SCR) for Baby T, aged three months, was commissioned in August 2012 after he was admitted to St Mary’s Hospital.
The report states he’d been taken to the hospital by his mother and her boyfriend, “because he was floppy, unresponsive and generally unwell”.
It goes on to say that “Further examination identified extensive bilateral retinal haemorrhaging indicative of severe trauma. The clinical opinion was that it was likely that this had been caused by being shaken by an adult.”
Catalogue of failings
As with the case of Baby X, the purpose of the SCR was to identify where failings took place, what lessons could be learnt and how child safeguarding could be improved on the Isle of Wight.
Sadly for the family and friends of Baby T, details set out in the report give a clear indication of the failings of former Children’s Services to protect the safety and well-being of this vulnerable family.
No criminal charges
At the time of the injury to Baby T, he was living with his mother and her partner as well as the father of his four year old sister.
As several people (four are named in the report) had been looking after Baby T prior to his injuries it was impossible to determine through medical evidence who was responsible, therefore criminal charges in relation to neglect were not taken to trial.
Known to Children’s Services
The mother of Baby T has been known to Isle of Wight Children’s Services since 11 December 2006. She was recognised as having past mental health problems and when pregnant with Baby T’s sister in 2007 was referred by her GP for an urgent assessment.
A psychiatrist identified a wide range of symptoms which would have been of concern with imminent childbirth. A teenage pregnancy midwife described the situation as being of ‘huge risk’ for the unborn baby.
However, three weeks later Children’s Services carried out an initial assessment and concluded that “the mother’s health had stabilised since the psychiatric assessment”.
Sister was a ‘Child in Need’
At a child protection conference at the end of September 2007 the mother said she was ‘fleeing domestic violence from the father’, who she said had significant mental health and social problems.
The unborn baby was concluded to be a ‘Child in Need’ but when Baby T’s older sister was born the mother returned to the mainland and a ‘Child in Need’ plan was never completed.
Concern raised over living conditions
It was not until May 2011 that Children’s Services next had contact with the family. They had returned to the Island and Baby T’s sister had started pre-school.
Children’s Services were contacted by staff at St Mary’s hospital because “a young person had taken an overdose and said that he lived with the mother on the Isle of Wight”.
No response or actions carried out
The out of hours Children’s Services worker raised concerns about the living conditions at the address and emailed the manager of the Referral and Assessment Team, requesting a home visit.
The report reveals no record of any response to this email, nor is there a record of any visit being undertaken in respect of the alleged home conditions.
‘Aunt’ reported problems
Near the end of 2011, the mother’s ‘aunt’ (her cousin) contacted Children’s Services with grave concerns, saying the mother was not looking after herself or her daughter.
The ‘aunt’ told the worker that the home smelt of urine, the mother was currently misusing alcohol, not taking her mental health medication, that the four year old daughter had to ‘fend for herself’ and eat the food she could find within the home.
Mother denied allegations
However, later that day the mother herself visited the First Response Unit and denied the allegations.
Her account was accepted and no further action was taken or home visit planned.
“This is a very vulnerable family”
During the pregnancy, the mother received several visits from various agencies including the community midwives and the Children’s Centre Family Support Worker (FSW).
At seven weeks old, a referral by the FSW stated, “I am aware that there is a long history with the mother and her daughter in Children’s Services and feel that this is a very vulnerable family”.
Conclusions
The report’s conclusions reveal that “the injury that Baby T received was both predictable and preventable”.
It includes information such as the father of Baby T’s sister, who was living with the mother, had told mental health workers that “he fantasised about hurting small animals and people and had been denied contact with another one of his children”.
The report adds that had “professionals assessed the dangers correctly and taken appropriate action in ensuring that Baby T was not left in the care of the daughter’s father then the harm that has befallen him would have been prevented.”
Disciplinary action?
OnTheWight waited almost two weeks for a response from the council to questions over whether any disciplinary action would be taken in either the Baby T or Baby X cases.
A spokesperson for the Isle of Wight council said,
“Since this Serious Case Review there have been significant changes in the management and leadership team which had responsibility for child protection on the Island. With regards to front line staff, disciplinary action has not been taken.
“Since the beginning of this year however, a great deal of work has taken place to improve services to children and their families on the island. All practitioners who work with children and families will need to consider the lessons from a review such as this and the Isle of Wight Safeguarding Board is leading that process.”
We put the same question to the IW NHS Trust. In respect of Baby T, Alan Sheward, Director of Nursing and Workforce, said,
“It is clear from this report that we could and should have done more as an organisation to ensure the safety of this child. We have undertaken a thorough review of the case and implemented a series of improvements to ensure that the likelihood that can happen again is minimised.”
The Report
The comprehensive Serious Care Review (embedded below) makes for very tragic reading.
Image: Comedy Nose under CC BY 2.0
