A serious case review has criticised an “incident-focused model” of responding to a family where a baby died.
The review into the death of a four-week-old baby, published last month, also found issues with a children’s services’ duty rota system of working with families, social workers operating without the assistance of risk assessment tools, and the use of written agreements that “protects the agency” rather than the family.
Individual agencies were “working independently of each other and so missed opportunities to work collaboratively to ensure the safety and well-being of children within the family”, it added.
Hull children’s services closed the case six months before the boy died in September 2014, and the review team said this was based on “incomplete and missing information” as they hadn’t collected information from other agencies.
Review authors also found issues with “subtle hierarchies” among partner agencies, which meant some tasks weren’t done because agencies didn’t feel that they were the right ones to do it, and some agencies were not listened to by social workers.
The death, which the Hull safeguarding board chair said could not have been anticipated, happened after the child was violently shaken by his father, who was later convicted of manslaughter.
The father had a history of domestic abuse with a previous partner and was not allowed to see his first child.
With the mother in this case he had two children, and he exerted a pattern of coercive and controlling behaviour – as well as physical violence – which was not picked up on by professionals. This was because the coercive aspects of domestic abuse were “not recognised by these professionals at the time”.
This serious case review picks up on the fact that social workers failed to spot the signs of coercive and controlling behaviour in the couple’s relationship. Community Care Inform Children subscribers can find advice on identifying these signs, as well as practice tips on what to do next, in our guide on how to identify coercive and controlling behaviour. Other useful practice guidance can also be found on the Inform Children’s domestic abuse knowledge and practice hub.
The response to incidents between the mother and father by children’s social care was to have a duty officer visit them. However, the review said these occurred “on an incident-by-incident basis and, therefore, the ongoing controlling nature of [the father’s] the behaviour was not recognised”.
“Working within an incident-focused model carries the risk of harm to children continuing unabated for long periods, and ignores the huge damage that will already have been done to victims by the time any action is taken,” the review said.
“Practitioners confirmed in discussions that had [the mother] presented with bruises and injuries, agency responses might well have been different. Police confirmed that their response would also have been different if signs of physical injuries had been seen and confirmed… at that time, officers handled verbal arguments differently to incidents of physical violence,” the review said.
The structure of the children’s services team handling the case was also “not ideal”, the review said. In total, nine duty different duty officers and social workers had contact with the family, which led to the case lacking consistency and planning.
“Practitioners found the arrangements not only challenging, in terms of their impact on the development of meaningful relationships, but also anxiety-provoking, as they were not working to any specific plans or goal-related work,” the review said.
There was a restructure midway through the review, which changed the service to focus on small social work teams known as ‘pods’ and led by a consultant social worker.
Different agencies all had individual pieces of information, but failed to share these with one another, the review said. This information included evidence about drug use, past domestic abuse, and mental health conditions.
“The significance of the combination of factors was, therefore, not recognised by practitioners as they each focused on their own discipline and area of expertise within their respective services,” the review said.
It identified how there was no “healthy scepticism” from practitioners to seek out missing information. It said this was due to the parents cooperating with services and a “pre-conceived view as to what ‘domestic abuse’ looked like”.
The review criticised how social workers had to rely on intuition in their practice as they didn’t use risk assessment tools. It said relying on intuition was dangerous because “of its potential as a source of bias”.
“Research studies suggest that ‘without the use of tools to assess risk, professional judgment can too often be flawed, with assessments being only slightly better than guessing’,” the review said.
It also found social workers had a “misplaced confidence” in a domestic abuse programme the father was undertaking, as they equated it as a safety measure for both of the children which “obscured and minimised the risks” evident.
A written agreement that the parents should not live together was “not a safety measure”, the review said, “but it did provide a degree of reassurance to social workers”.
“The review team considered that the use of these ‘written agreements’ could too easily become practice that protects the agency rather than as part of a working plan aimed to protect children.”
Professionals’ determination of the family’s needs and risks posed were “significantly influenced” by “’subtle hierarchies’ within the system,” the review said.
“This led to information being ‘weighted differently’ dependent upon the source and the perceived ‘expertise’ of that source.”
An example of this was when staff working in the hostels where the parents were living voiced concerns. Duty social workers did not see these concerns as significant, despite the hostel’s considerable involvement with the parents and that the hostel workers themselves were in fact qualified social workers.
“This left hostel staff feeling devalued and that their concerns were not ‘heard’ or well understood,” the review said.
Domestic abuse response
Rick Proctor, independent chair of Hull Safeguarding Children Board, said the review highlighted the need to improve early help, the gathering and sharing of information, and pre-birth assessment and planning in Hull.
“Above all there is learning about responding to domestic abuse, and, in particular, the challenges for practitioners where coercive control may be a feature in relationships and where victims may find it difficult to talk to professionals about what their life is like. This case also highlighted the need to ensure direct engagement with men and fathers in assessment and work with families,” Proctor said.
Since the child died, the safeguarding board had implemented a pre-birth vulnerability pathway to strengthen joint work, influenced a new cross-partnership steering group on domestic abuse, and agreed a ‘whole partnership’ review of domestic abuse training.