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The case involved the abuse and neglect of a 5 month old child by his father.

The child’s parents were both known to a number of universal and specialist services throughout their lives. They were “not below the radar of services”.

Mother had 2 previous children removed due to her capacity to care for them. She was also known to have a learning disability and a significant hearing impairment.

Father had been the victim of physical abuse as a child. He had some special needs, suffered from ADHD, depression and suicidal thoughts. He left home at 16 and spent time sleeping rough and in hostels. He had a number of minor convictions for burglary and drunken disorder.

The parents met when both were residents in the same supported hostel accommodation.

Child J was born in June 2013 and removed at birth and placed into foster care.

Father put himself forward as a suitable carer for J and a number of assessments were undertaken.

In October 2013 the court placed Child J with his father on a full-time basis. This was supported by a package of visits and interventions.

Within a month of Child J residing with his father — J had sustained a number of non-accidental injuries.

Child J was removed from his fathers care in November 2013 and returned to his original foster carers.

Father was subsequently charged with neglect and received a community sentence.

Learning from the Review

  • It is considered good practice that Child J was placed with foster carers who had looked after his half-siblings
  • It is considered good practice that the midwifery service challenged the hospital discharge plan
  • It is considered good practice that the GPs fully undressed Child J and as a consequence observed additional injuries
  • There was “a premature intention to place Child J with his father on a permanent basis and the role of optimism”. Plans were predicated on an insufficient understanding of risk and a tendency to be over optimistic. There appears to be no point at which a reflection was taken of all that was known.
  • “Lack of compliance with procedures” There were a number of instances where Child Protection procedures were not followed including failure to follow the Bruising in Pre-mobile Babies procedure.
  • “Disguised Compliance” Professionals should always be alert to the possibility that families will appear compliant with plans but in fact be avoiding doing so
  • “Holistic Assessments” There was an unacceptable evaluation of risk. This resulted in the information being placed before the court to enable them to decide where J should live was incomplete.
  • “Information Sharing” Information appears to have been confined to communication between Children Social Care, The Guardian and Support Services

Implications for Practice

  • All agencies must use the escalation policy and ensure that their concerns are properly recorded
  • When threshold is met, Initial Child Protection Conferences must be held without delay and risk discussed thoroughly with the involvement of all partners
  • All plans including CLA plans must be reviewed following a relevant change in circumstances and the impact of this change on risk considered
  • Assessments must be based on information available from all partners involved and the outcomes and recommendations shared with these partners following completion
  • All care options must be considered and contingency planning undertaken and a full understanding of risk considered based on thorough assessments.
  • Any bruising on non-mobile babies must be dealt with in accordance with the policy
  • All agencies should consider disguised compliance when working with families.
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