How Doncaster council workers missed opportunities to save baby Christopher

A COUNCIL investigation into a the death of a baby who was shaken by his mother's partner has found his life could have been spared, but for 'missed opportunities' to improve his welfare.

By The Newsroom

Published 17th Nov 2016, 10:30 BST

Updated 18th Nov 2016, 12:22 BST

Laura Ostle, from Doncaster, at Sheffield Crown Court. Picture: Ross Parry Agency

Laura Ostle, from Doncaster, at Sheffield Crown Court. Picture: Ross Parry Agency

A jury at Sheffield Crown Court heard that Christopher Larkin died in hospital a day after he was violently shaken, in September 2014. He was just under three months old.James Larkin, 26, was jailed for 12 years and his former girlfriend, Laura Ostle, 21, was jailed for 18 months for trying to cover up the killing at the couple’s home in Doncaster.But a report published by Doncaster Safeguarding Children’s Board found Christopher’s death could have been avoided.The findings of the review echoe the conclusion of three of the seven serious case reviews into child deaths that led to Doncaster Council being stripped of responsibility for children’s services and the establishment of the Doncaster Children’s Services Trust, where information was not shared between agencies.The report concludes that not enough information was being shared across adult services so an ‘assessment of risk’ was never carried out on the dysfunctional family.On multiple occasions, social services were called upon and with Ostle moving house and missing appointments. It took at least eight months for contact to be made.The report said: “It is clear that the work of professionals with Child A [Christopher] was limited in its effectiveness and there were missed opportunities to improve Child A’s welfare.”It found that information was not shared between Doncaster Children’s Services Trust, set up just after Christopher’s death in October 2014, and other agencies.The report said: “Had this [assessment] taken place it may have resulted in an earlier referral to children’s social care. “This would have ensured an improved understanding of the risks to the safety and welfare of baby, known as ‘Child A’ [Christopher].”Healthcare professionals first became involved with the then teenage Ostle in 2012, when she became pregnant with her first child, Christopher’s sibling.A case was opened into Ostle and her history of depression, issues relating to her deteriorating mental health, transient lifestyle and financial needs.But, despite missing post-natal hospital appointments, the case was closed in January 2013 after the baby was born.During the manslaughter case which eventually found Larkin guilty, a jury heard it was the former Territorial Army recruit who helped raise Ostle’s first child - despite not being the biological father.At his sentencing, the court heard Larkin was treated “like a doormat” and attended to both children when Christopher was born, and even when Ostle brought other men around to the house, he still looked after them.He would wake up in the middle of the night and feed and change the nappy of Christopher.Recorder of Sheffield, Lady Justice Andrews told Larkin: “Laura undoubtedly took advantage of you. “I take into account that she was diagnosed with an attachment disorder when she was only aged seven, for which she received counselling for many years. “This goes to explain some of her unattractive behaviour - especially those which were attention-seeking - but it does not account her for treating you like a doormat.” During the run up to Christopher’s birth in late 2013 - the alarm bells started ringing for agency nurses.Ostle consistenly missed appointments and midwives were never be able to contact her on the phone.A distressed midwife also made a referral to the Intensive Family Support Service [IFSS] - an early help support service for vulnerable families.The IFSS also made a number of unsuccessful attempts to contact the family. But a social worker was not allocated to the family until after Christopher was born in June 30, 2014 - more than eight months later.Social workers had regular contact with the family and concerns were raised again about Ostle’s behaviour and her mental health, and the couple’s accessing of health services.The last visit took place days before Christopher’s death, on September 11 2014, when Ostle again raised concern about her baby son’s health.The report noted there were challenges in working with Larkin and Ostle, who were described as ‘young and inexperienced parents’. It stated due to their frequent moving of address - it resulted in many changes of health professionals and made worse by Ostle failing to attend appointments. The report added: “Whilst recognising those challenges, it is clear, nevertheless, that the work of professionals with Child A was limited in its effectiveness and there were missed opportunities to improve Child A’s welfare. “Professionals did not display sufficient curiosity, particularly in considering the role of Adult B [Larkin] - who was taking on care responsibilities for a baby.”Paramedics were called to the couple’s home in Doncaster, South Yorks., on September 16, 2014. The court heard upon attending they found the baby in cardiac arrest - but Larkin had “perpetuated a medical emergency” to justify shaking Christopher “back to life”. Larkin was found guilty of manslaughter, perverting the course of justice and conspiracy to pervert the course of justice. Ostle was also found guilty of perverting the course of justice and conspiracy to pervert the course of justice. Speaking about how the case was handled, John Harris, independent chairman of Doncaster Safeguarding Children’s Board, said: “What happened to Child A is very distressing. “The findings and recommendations from this review are of huge importance in Doncaster and are informing the drive to improve safeguarding across the borough. “The review enabled us to identify key learning points about the effectiveness of early help, the response to neglect, information sharing and pre-birth assessment and planning. “A robust action plan was created, building on the findings, and many of the recommendations have already been acted on, but there is still more to do. “Since this case occurred, a more robust approach to risk is being adopted, through the ‘Signs of Safety’ practice model, which is also improving the engagement between professionals and families. “Better management oversight is also increasing the likelihood of risk being identified consistently and at the right time. “As a result, the DSCB is confident that a situation like Child A’s is less likely to happen again.”