About the Family Law Week blog

The Family Law Week Blog is a companion site to Family Law Week. It complements the news, cases and articles published on Family Law Week with additional comment and coverage of the wider aspects of family law.

The Blog is edited by Jacqui Gilliatt, of 4 Brick Court and Lucy Reed, of St Johns Chambers.

Monday, 8 November 2010

Baby P Serious Case Review

Serious Case Reviews are carried out under Regulation 5 of the Local Safeguarding Children Board Regulations 2006 which requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2006).


From the 2nd SCR into the Baby P case, it is clear that Haringey were aware of the presence in the home at least on occasions of Mr H (the mother's boyfriend) but it was always said that he was a friend and there was no evidence that he was living in the household, even from interviews with the children themselves. However, the mother's own account was simply taken at face value. There was no adequate follow up when the father suggested that Mr H was in fact a boyfriend. Mother was asked but denied it - although she did say she would like to date him. The rather obvious conclusion is reached that it should be standard practice to investigate the role of any man who is involved with a family where children are in need / known to SSD and that the wider agency network must report any such suspected involvement.

Following an injury resulting in hospital admission in December and said by the Paediatrician to have been caused non-accidentally the children were placed with a family friend of the mother's choosing. This placement gave the wrong message to the mother about the seriousness with which injuries to the child were viewed. While family members and friends should be seriously considered in many cases in injury cases considerably more caution should be exercised.

An early Paediatric view that injuries were non-accidental and the explanations offered for them was not given sufficient weight at the first CPC. Regrettably the Paediatrician did not attend the CPC.

After the CPC LB Haringey was given advice that the threshold for care proceedings was met although the older children of the mother were not placed on the at risk register. Proceedings were nonetheless not issued and they should have been.

The CPC was not reconvened when further serious head injuries were discovered in March, again resulting in hospital admission. No strategy meeting was held. Very little investigation of the mother's account was carried out. The police were not informed. Proceedings were not brought and they should have been. The SCR comments that the onus should have been placed on the mother at this stage to prove that the injuries were non-accidental in the light of the history and previous s 47 investigations.

After a further episode of injury to a child at the beginning of June (multiple bruising & scratch marks but including what looked like grip mark bruising to the legs) there was disagreement between the police and SSD about bringing proceedings, the police thinking that an EPO could and should be granted. The police did not, however, investigate themselves but left it to the SW to do. The injuries had not been reported but were picked up by the social worker on an unannounced visit. SSD did not take legal advice and implemented a plan involving the family friend moving in to ensure there was not unsupervised contact between mother and the injured child. When the CPC Review was eventually held a number of key agencies were unrepresented and there was no legal adviser present. The Review meeting was told that a legal planning meeting would be held within a week. This did not happen and it was 7 weeks before it did. At a subsequent visit to the home Mr H was present but again no alarm bells seemed to ring. However, over the next few weeks the observed interactions between mother and the children were all fairly positive. The child was noted to be unhappy at school and the mother continued to be neglectful and hostile although she participated in a parenting programme (attending 9 out of 13 sessions but only taking the child on 4 occasions). She also absented herself and the children from the borough for a couple of weeks supposedly to look after a sick uncle.

By the time the legal planning meeting had taken place there were further medical issues - the child had a sore ear thought to be caused by an infection, though mother did also admit to causing bruising while trying to clean it. He also had serious head lice and an infected scalp. He was reported to be head banging though not when in the care of the family friend.

The SCR's conclusions on the legal planning meeting are set out below and I have highlighted the particularly important section about potential disagreements between LA lawyers and their instructing social workers.

The long awaited legal planning meeting eventually took place on 25 July. The lawyer was relatively inexperienced in advising in care proceedings and it became clear that the SW and her TM were reluctant to consider care proceedings; they did not see the necessity for them. The conviction demonstrated at the child protection conference on the 8 June had dissipated. Despite the long delay the lawyer was without the medical report of the injuries on X XXX. The background information was incomplete. On that basis the lawyer did not think they could advise on whether the threshold was met at that time. In any event, even if the threshold had been met, it was the TM’s decision whether to initiate them or not. The threshold was met. The original injuries to child A met the threshold for care proceedings and that carried through alongside any subsequent injuries. Legal services accept completely that the service in this case was inefficient and did not meet the standard required, and they have made improvements to prevent a recurrence. They also accept that they have an independent safeguarding responsibility to any child, and that if they disagree with the decision of a TM then they have a duty to make representation to managers responsible for them.

3.22.6 It can be an unfortunate feature of the understandings in the work that whether the parent is prosecuted or not can become conflated with the degree of risk to the child, and whether care proceedings should be initiated. They are different considerations with different thresholds for action. However they can be become unhelpfully misunderstood around the injuries to the child and the medical opinion. The police are concerned with evidence and place importance on the indications of injuries and the weight which doctors will give to them. Other services can also place importance on the medical opinion of the injuries, too much importance, and they wait for the outcome of the police and CPS’ view of them. If they are not to lead to a prosecution the cause of the injuries can become regarded as uncertain and even accidental. The police accept that it took an unacceptably long time to resolve the position on the original injuries to child A.

3.22.7 The delay was due to a combination of administrative failure, a change of jobs, collecting evidence at the time, and the very long time it took to obtain a second medical opinion. That opinion was that the injuries were probably non-accidental but the CPS judged that it was not strong enough for a successful prosecution.

Interestingly the child stayed with his father for an overnight visit in the last few days of his life.

Continuing concerns about the child's physical presentation and scalp infection but seemingly not in relation to suspected injuries.

2nd August - the police confirmed no further action on prosecutions.

3rd August the child died.

The SCR identifies the failings in this case as being the lack of an authoritative response to very serious concerns about the care of the child, an approach treating incidents as a series of unrelated and unfortunate episodes rather than linked or forming a pattern, a lack of any real challenge to the mother's accounts, a failure to take care proceedings, and an incorrect assumption that proceedings could not be justified unless there was evidence of non-accidental injury which satisfied the criminal standard.

Comparing the First SCR and the second reviews, the first review contains a lot more detail and makes some very specific recommendations of good practice in future. Both reviews are critical of some of the professionals involved in the case, although the first one also recognises that there was good practice in the mix. The main difference is in the overall conclusions set out above and the overall conclusion that expectations of parenting standards in Haringey were too low. In fact the second review, whilst describing the first as unsatisfactory did not dissent from its specific recommendations for improving practice. For the benefit of LA lawyers the relevant paragraphs in the first review are at 6.8, 6.24.12, 7.4.33- 36 & 8.3.31-37.

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