Report into death of two-year-old child criticises Thurrock Council

A LONG-awaited serious case review into the death of a Thurrock toddler and the care offered by Thurrock Council Children’s Social Services to her, her brother and family has revealed a series of significant failings by the authority.

The thirty-one page report detail the events leading up to the death of two-year-old Sam in January 2018.

Much of the report details the interactions by a number of agencies with the family.

https://www.thurrocklscp.org.uk/assets/1/scr_sam___kyle_-_final.pdf

YT has selected a number of comments and recommendations.

Paragraph 47

Although concerns remained, the parents made it clear that they did not want or felt they needed further support and the case was closed to Early Offer of Help. All professionals at the meeting (midwife, nursery, Parental Outreach Worker; Health Visitor gave apologies) were content for this to happen and did not offer any professional challenge to this decision despite the fact that concerns were still current. This was despite a continuing range of incidents and concerns over the previous few months about Kyle’s behaviour and wellbeing and parents’ capacity to keep Kyle safe – and the arrival of a new baby which added new strains on the family. Mother stated that she felt she was establishing a routine with Sam, but that Kyle was disruptive. All these factors challenge, in hindsight, whether the decision to close the case was appropriate. Without parental consent to continue with the Early Offer of Help, this presented a dilemma, but a more risk-aware decision would have been to try to maintain involvement, as the substance of the concerns and risks had not changed, or to refer for Social Care assessment in order to establish a refreshed and comprehensive picture of the strengths and challenges facing this family.

Paragraph 74

For two critical periods – from the final months of the Supervision Order in September 2014 through to May 2015 – and from the closure of Early Offer of Help in February 2016 through to at least May and possibly September 2017 – there was little coordinated oversight of how well this family was doing, what help they might be offered, and what their engagement or lack of it, meant for the risks to the children. When Health Visitor and educational staff began to raise concerns in 2017 it took a total of six months before these were comprehensively assessed, with the eventual conclusion that Social Care intervention was appropriate.

Paragraph 78

There are a number of instances when information was not shared or was available between agencies and professionals working with the family. There was little linkage between the GPs and health visiting or other agencies, so GP when they saw mother and children, were not fully aware of the history of concerns, or of the vulnerability of mother.

Paragraph 90

When working with a family in different situations and setting it is inevitable the different impression and assessment will be made. Open and frequent communication between professionals is essential to ensure that these interpretations are checked out, confirmed or modified, and that a consistent and common plan of advice, care and support is agreed with the family. Even when there were regular multi-agency meetings in this case, it is not always clear that there was a shared and agreed plan – either with the family or with other professionals. Meeting notes record actions and follow-up, but do not reflect clear goals, constraints or consequences if things do not go to plan. This was especially true during 2017. This made it difficult for the family to own and complete the goals for themselves and led to confusion over responsibilities and options for professionals. Setting out a clear care plan – at whatever Tier or level of intervention – which was shared and accepted by all agencies – would have provided a more robust framework for this family and enabled a more consistent judgement to be made as to whether things were improving for Kyle and Sam.

Paragraph 104

Nursery, school education and health visiting were universal services that kept in touch with this family and were concerned about their welfare and noted the impact of neglect on the children. During the periods when there were regular Looked after Child reviews or Team Around the Child meetings it was easier to co-ordinate the work between universal, targeted and specialist services. When these meetings lapsed, or there were long gaps, this became more difficult and led to frustration between partner agencies.

Paragraph 107

The role of the Case Manager within the Prevention and Support Service is now to offer advice, guidance and support to professionals working alongside children and their families. They will also provide direct intervention with families, based on their individual specialisms within PASS. The role is pivotal in offering consultation, signposting and allocation of the most appropriate services which will, include multi agency service provision. This role was underdeveloped in 2017 when PASS worked with this family and this led to a lack of clarity in who was leading work and what direct work was intended to take place. Mother has said that more immediate and practical help would have been helpful, which was not provided during the PASS involvement in 2017.

Paragraph 111

The challenges for this family and the concerns articulated by professionals did not significantly change from before Kyle’s birth until Sam’s death. However, the case was managed over six years in a variety of different ways and without clear overall objectives which connected each separate intervention and linked separate episodes and plans together. This did not make it easy for mother and father to appreciate professionals’ concerns or to have a consistent framework within which to develop their parenting skills and confidence. At times the emphasis was on their needs – at others on the children. Both parents loved their children and wanted to care for them well but needed clear encouragement and direction in order to do so safely. Parents were inexperienced and lacked role models for positive parenting, were not able to prioritise consistently the needs of the children, were not able to provide a safe and clean home environment, were inconsistent in their approach, and found it difficult to set appropriate boundaries for the children or on their own behaviour.

Paragraph 119

From May 2017 the family was supported through the Prevention and Support Service programme. There is a disjuncture between the continuing concerns raised by the Health Visitor and by nursery and school as they prepared for Kyle to attend in September 2017, and the assurance from the Prevention and Support Service programme that things were improving. In the recording there are no firm dates when visits were made (other than by the Health Visitor which are separately recorded). Several of the entries in the notes of the review meetings are repeated for succeeding meetings – making it unclear to what and when they relate. The interventions from a Family Support Worker, which were proposed in the autumn 2017 in the face of repeated requests from the other professionals for a more active engagement, did not take place. It appears that other professionals felt inhibited from escalating the case because the Prevention and Support Service were involved but were equally frustrated by the lack of progress or urgency. When the concerns resulted in a social work referral, visit and assessment in December 2017, the concerns quickly led to a recognition by Children’s Social Care that there were significant issues to be addressed. Sam’s tragic death, from unrelated and unknown causes, was unrelated to the issues that prompted a Child Protection Conference and the decision to take Kyle into care.

Paragraph 120

It was clear from discussions at the Practitioner Event that the level of cooperation and trust between professionals and different agencies had been less than ideal. There were different views about the level of concerns and what was the appropriate way to respond to them. There were differences of opinion around thresholds and on the impact of circumstances on the children. This illustrated that these concerns had not been escalated or resolved at the time. There was some uncertainty about whether all professionals were aware of how to escalate concerns, both within their own organisations or with partner agencies.

Thurrock Council’s full statement today is published below:

Commenting on the report, Leader of Thurrock Council, Cllr Rob Gledhill said “Any child death is a tragedy and a deep loss for the family to which we continue to offer our condolences. The SCR, based on the Coroner’s report, concluded that the death was from ‘unrelated and unknown causes’, therefore no organisation or individual is responsible for the tragic death. Post-mortem investigations did not establish a cause of death, which was recorded as unascertained at inquest – this can also be known as unexplained death such as ‘cot death’ or Sudden Infant Death Syndrome.

“It was right to commission a SCR to review and identify any learning for the agencies working with the family. The report makes a number of recommendations and raises areas for improvement which includes better partnership working to support this family from when they became known to Children’s Services in Thurrock in 2012.

“The issue of learning in safeguarding is important for all partners and this has been identified to have improved in the recent Ofsted inspection of the council’s Children’s Services in November 2019. The Cabinet Member for Social Care has asked that this SCR report be referred to our Children’s Overview and Scrutiny Committee, with a proposed action plan developed to ensure that the Thurrock Safeguarding Children’s Partnership is held to account and the recommendations in this report fully addressed.

“All SCRs progress at different speeds due to the individual circumstances of each one, this report took time due to the pressures nationally in the Coroner’s service as well as ensuring the family affected was given appropriate time to consider the drafts of the report.”

Looking to the future, Cllr James Halden, Cabinet Member for Social Care, said “An independent review of the Thurrock Safeguarding Children’s Partnership has already been commissioned and in my mind it is vital – we need to ensure the partnership has enough capacity, independent challenge and that it actions SCRs, or Child Safeguarding Practice Reviews as they are now known, quickly and robustly. This review of the partnership had already been agreed and is not a direct response to this or any other SCR.

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