Agencies have pledged to continue to improve the ways they safeguard children following the publication of a Serious Case Review (SCR).
The review was started after the death of three-week-old Baby ‘Eve’ in Northumberland in March 2013. The baby’s mother pleaded guilty to neglect and was given a six-month prison sentence, suspended for two years, in October 2014.
The review, commissioned by the Local Safeguarding Children Board (LSCB) found there were a number of lessons for agencies which had duties relating to supporting the welfare of Baby Eve and her family.
Independent chairman of the LSCB, Paula Mead said: “Baby Eve’s death was tragic and collectively, we regret that there were several areas where agencies could, and should have done better.
“With hindsight, there were a number of occasions in the months immediately before Baby Eve’s birth, and earlier during her mother’s pregnancy when professionals in a number of agencies could have acted differently and worked more effectively together.
“While we cannot say that if they had done so, Baby Eve’s death would have been avoided, we can say that many of our agencies could and should have responded more proficiently and had much better processes in place.”
The Board found several areas requiring attention including:
○ The need to improve the quality of supervision and the management of staff dealing with challenging cases and ensuring there is reflective and robust analysis of cases.
○ The review and improvement of record keeping across parts of the health and social-care system.
○ The improvement of systems to invite professionals to child-protection meetings, to record attendance and to pro-actively follow up any gaps in attendance and involvement.
○ The escalation of concerns to a more senior level when front-line multi-agency interventions are identified as not being effective.
○ Involving children in their assessments and care plans and making sure their voice is heard.
○ Recognising when parents appear to cooperate with professionals but aren’t effecting sufficient changes to their parenting and identifying the long-term impact of that on their children’s lives.
Ms Mead continued: “Our role is to safeguard and protect children and it is clear there were failings in this case which we fully accept and have worked to address.”
As the review was being conducted both the LSCB and the individual agencies have responded to the issues as they have been identified.
These have included:
○ The multi-agency guidance relating to the birth plan has been updated for all children who are a ‘child in need’ or have a child protection plan.
○ The re-writing of operational guidance around caring for substance-using pregnant women.
○ Developing a series of workshops for staff from all-partner agencies on the issues raised by this case; the lessons learned from this review; and the actions which have been put in place to reduce the risk of similar mistakes.
○ Improvements to the invitation to child protection meetings and the distribution of minutes to all key agencies, whether they are in attendance or not.
Ms Mead concluded: “While there were 16 recommendations, the LSCB has been developing a comprehensive action plan to make sure all actions are either completed or underway.
“We recognise that we need to keep on working effectively with each other to support families and to protect young people from harm as far as we’re able. The public can be reassured we will continue to rigorously enforce the learning from this SCR to ensure similar errors are not repeated.”