A review into “Child T” has uncovered a raft of missed opportunities and inadequate responses from council, Cleveland Police and safeguarding teams after the youngster survived an attack by his mother last year.
The mother was subsequently convicted and is serving a custodial sentence. The injured youngster is now in foster care.
A detailed 37-page report listed how sole parental responsibility for Child T – and his sibling – was returned to the mother by a court in late 2019 as her mental health was deteriorating.
Social care teams “stepped-down” the case and referred the family to the Early Help service before the attack.
The attempt on Child T’s life happened four years on from suffering a broken leg where no “recognisable form” of police investigation was carried out, and after which social care teams decided to return him home with his mother.
Independent reviewer Dr Jeremy Pearson found Child T was a vulnerable four-week old baby who’d received an “extremely serious non-accidental injury” when he first came to the attention of agencies.
His report went on to judge the youngster was exposed to further risk of harm by the “inadequate response” of bodies tasked with keeping vulnerable children safe.
The report added: “Given the extensive history associated with the case, and the overriding imperative to protect Child T, safeguarding agencies should have retained a determined focus on ensuring that Mother did not pose a current or future risk to either child.
“This failed to happen, and the recommendations contained within this report are intended to address these failings and to minimise the risk of recurrence.”
What is it?
Child safeguarding reviews are launched when abuse or neglect of a child is known or suspected – and a child has either died or has been seriously harmed.
Formerly known as serious case reviews, the probes look over how professionals and bodies can improve how they work together and learn lessons to prevent similar terrible cases from happening again.
The unflinching report from the Hartlepool and Stockton Safeguarding Children Partnership offered a run-down of how agencies had slipped up in keeping Child T from 2016.
It was published in March and key concerns were set out – including the response to the baby’s broken leg in February 2016, the actions of a court in awarding joint parental responsibility of children to both the mother and the council in August that year, and the decision to step down social care services and close the case in 2020.
Dr Pearson’s probe set out to examine whether Child T’s broken leg in 2016 was a precursor to the later attack, whether family court decision-making was appropriate, and whether the decline in the mother’s mental health was properly risk-assessed.
“Non-accidental” broken leg
The review showed how the mother in this case had suffered a troubled upbringing – which hadn’t helped her mental health. The report also showed she had a past criminal conviction.
She was also detained in a mental health facility in the past where she was later diagnosed with a personality disorder.
Child T was born in January 2016 with initial contact made by the council’s “Mother by Footsteps” scheme, whose staff raised no concerns at the time of visiting.
But when the youngster was just four weeks old, his mother rang 111 as he wasn’t moving his leg. Investigations and x-rays found he’d suffered a broken femur in the previous 10 days.
James Cook Hospital A&E workers contacted Stockton Council’s social care teams with concerns about the injury – triggering background checks on the mother.
She denied causing the injuries – suggesting it could have happened while she’d been breast-feeding. But a hospital doctor believed the broken leg was “non-accidental”.
A joint strategy meeting between police and social care teams was held that evening – agreeing the mother should not have unsupervised access to Child T.
But a follow up meeting a few days later then judged the mother could return to her home address with both of her children – as long as 24-hour supervision using friends and neighbours was in place.
Follow up visits then found the mother and her children were left unsupervised on five separate occasions. The family was then moved to a facility where round-the-clock supervision was provided.
But the review found the mother was “uncooperative” and “persistently challenging towards staff”.
It was reported the situation became so toxic that a number of staff at the facility began cancelling shifts due to her behaviour.
A more detailed medical report was then released on the leg injury in April 2016.
The probe added: “This type of injury is known among child protection professionals as a twist injury – and is recognised as being almost impossible to be caused accidentally.”
Dr Pearson’s analysis of the episode found social workers and the police appeared to have properly checked databases after the leg break.
But his report found the subsequent management of the case had a “lack of focus and rigour” – with the joint investigation into its wider circumstances appearing to have not happened “to any great extent, if at all”.
Focus was placed on Cleveland Police – with officers initially recording the incident as a crime.
The review found the gravity of the offence and the victim’s vulnerability would usually have brought a comprehensive investigation of the circumstances by police.
But the probe found there was “no evidence” to suggest police officers had formed an investigative strategy, nor that they had conducted “any recognisable form of investigation”.
Dr Pearson added the mother was never interviewed by the police – despite telling medical staff she was the sole carer of Child T 10 days before she reported the leg injury.
And the review stated this, alongside medical opinion that the injury was not accidental, should have seen the police categorise the Mother as a suspected offender.
The report added: “Cleveland Police additionally failed to provide any file of evidence to the CPS. Given the available medical evidence, and the relatively uncomplicated nature of the enquiry, these investigative failures represent fundamental errors on the part of the force.”
Dr Pearson’s report also found the decision to immediately return Child T home after leaving hospital was “questionable” – particularly given the mother had a personality disorder and had the potential to commit acts likely to endanger others.
He also found the arrangements to ensure the mother wasn’t left alone with her children were “extremely lax” given how severe Child T’s injuries were.
The 24-hour supervision by friends, neighbours and social workers was also considered “unusually optimistic” by the probe.
The report added: “The arrangements implemented in this case were inadequate and did not provide immediate protective action.
“The local authority should have taken a more robust stance towards safeguarding Child T in those critical early days by separating him from mother.”
The review also found other opportunities to decisively intervene – and remove Child T from his mother – were missed in the following months.
Mother’s behaviour in the 24-hour monitored facility “should have acted as a red flag” to the risk to both children.
And Dr Pearson’s report stated the medical report on the leg break should have been the “final tipping point” for agencies to understand the risk the mother posed to her children.
Court action took place throughout 2016 with an initial order for the council to find alternatives to the mother’s two children being placed in foster care.
The review stated that the court would not remove the children from their mother despite her “challenging behaviour” at the supported living facility – with a 12-week order for an assessment of the mother’s parenting ability in April 2016.
A fact-finding hearing was held in May to judge how Child T’s injuries were caused.
It judged that the mother had been responsible – and the court believed it represented “a much-regretted loss of self-control”.
An assessment of the mother was carried out in a separate facility where she appeared to “present very well” to those reviewing her.
She was given a verbal warning for how she interacted with staff – but doctors noted she appeared to be “functioning well enough”.
A medical report was received by the court in July 2016 which found they “did not find evidence of current mental illness”, although a degree of caution and vigilance was advised.
This report recommended both children return home in the care of the mother.
The council’s view was the children should be adopted and leaving them in the mother’s care was “too great a risk”.
But the children’s guardian and the independent review officer, who carried out the initial assessment, recommended the children should remain with the mother.
The council changed its position in the August when faced with opposition – agreeing to share joint parental authority for the children with the mother, and accepting the family should return home.
The decision was ratified by the court later that month.
“Uncomfortable” with court decisions
Dr Pearson’s report found the court’s instruction for the council to look at alternatives to foster care “appeared unusual” given the circumstances.
He found the council’s bid to place the children in foster care was “entirely appropriate” – and the court’s decision to explore alternatives was “questionable” and a “missed opportunity”.
The court’s view that the mother and her children should not be separated despite “compelling reasons” was also labelled a missed opportunity.
And the judgement that the broken leg was a “much-regretted loss of self-control” was analysed as showing the court’s stance “could be best described as sympathetic”.
Dr Pearson’s review also stated the result of the fact-finding hearing against the mother – relating to the broken leg – was never sent to Cleveland Police.
It added: “If informed of this fact, the police may well have been prompted to finally begin to properly investigate the crime committed against Child T. And it would almost certainly have been viewed as relevant by the CPS had a file of evidence ever been submitted.”
The probe urged the police to be informed of these types of judgements made in family courts in future.
And the ruling for responsibility to be shared between the council and the mother was also seen as a missed opportunity by the review – with the probe revealing some practitioners were “uncomfortable” with the decisions of the court.
Dr Pearson’s report judged the first responsibility of agencies should have been to protect Child T and his sibling – adding that they took an “overly optimistic view” of the mother’s parenting ability and underestimated her ability to cause harm.
The report added:” This represents a serious failing, and some professionals appear to have exhibited a lack of objectivity in their decision making.”
The probe also highlighted concerns about how professionals had flagged up worries about the mother during 2017 and 2018.
These related “fabricated or induced illness” (FII) – which the NHS states is a rare form of child abuse where a parent or carer exaggerates or deliberately causes symptoms of illness in a child.
Cases were listed in the report – including the mother’s untrue claims that six paramedics were needed to revive an unconscious Child T.
The review showed significant concerns were raised about these cases in 2018 – with a conference triggered later that year and the mother invited along.
It added: “The view of the lead medical professional present at the conference was that Mother tended to exaggerate Child T’s symptoms, misreports the outcome of consultations, and sought changes in professionals who did not agree with her views.”
A doctor concluded it was “not a case of true FII” but it did have the potential to harm the child if it was allowed to continue.
And the collective view of professionals was the risk the FII had “lessened significantly” following another risk assessment.
Dr Pearson found the long list of suspicions “extremely troubling” adding the “sea change” which saw professionals reassured by the mother’s explanations was “striking”.
And he believed the conduct of the mother in the months leading to the conference should have led to suspicions her mental health was beginning to deteriorate.
The report added: “This behaviour should have acted as a red flag to the local authority who at that time still retained joint-parental responsibility for Child T and sibling.
“Given that mother was known to have been previously diagnosed with personality disorder, a mental health assessment should have been commissioned at this point. However, no such assessment was ever conducted.”
More “red flags” missed
As 2018 became 2019, the council judged the mother’s behaviour had stabilised and the probe added concerns over her children’s welfare “fast receded”.
A legal meeting in June 2019 agreed there was no justification for the shared responsibility to continue – with an application to the court to revoke the existing care order.
Further checks on the mother’s mental health were carried out in August – with no concerns flagged up.
However, the report showed that during 2019 the Tees, Esk and Wear Valley mental health trust (TEWV) made a referral linked to the mother’s self-reporting obsessive-compulsive disorder (OCD) symptoms.
The probe added these took the form of obsessive cleaning and anxiety that her children would become ill if she didn’t clean.
“Mother also disclosed that she was restricting her own food intake, cutting herself as a coping strategy, and that she had a long history of this type of behaviour,” the report added.
“This resulted in ongoing support from the Affective Team being provided and medication was prescribed.
“As a result of these disclosures, the potential impact of mother’s mental health on the children was discussed with Children’s Social Care on several occasions.”
The mother also made two calls to the North East Ambulance Service in 2019 to report she’d self harmed.
The removal of the care order was carried out in December that year to return sole parental responsibility for Child T and his sibling to their mother.
Dr Pearson believed the decision appeared to have been taken without all relevant material being considered.
Tellingly, information from the ambulance services and the referral relating to self-harm, OCD and a potential eating disorder was not considered in the final decision to remove the care order.
And the report added these should have once again been “red flags” to agencies that the mother was struggling to cope.
The review added: “There is no evidence that any robust, inter-agency examination of Mother’s mental health took place before an application was made to court to discharge the care order.
“If this had occurred, it is likely that it would have led to a far greater understanding of the risk represented by Mother’s fragile mental health condition.”
Unaware of self-harm as care stepped down
The report detailed how one feature of the relationship between mother and Child T’s had been her insistence he had autism despite him having no diagnosis.
CAHMS (Children and Adolescent Mental Health Services) received a referral for an autism assessment of Child T in early 2020 – with the mother revealing she suffered from severe OCD during an assessment by a social worker.
The mother’s GP surgery also noted a marked increase in contact from her – most of which related to her worries about the health of Child T.
The probe shows it was around this time the mother’s relationship with her children’s school got worse – with the mother suggesting Child T was suffering from Covid and the school should be closed down.
As the pandemic took grip, the decision was taken to end children’s social care involvement in the case – and step it down to the Early Help service.
Dr Pearson’s probe revealed information emerged during the review suggesting health visitors had been aware of the mother attempting to self-harm.
But social care teams were unaware of this – something the review judged was another failure in communication.
The review found the decision to step down services was made without multi-agency discussion – with some agencies finding out the decision from the mother herself.
This was judged to be a “serious failing” by social care – and meant “potentially vital” information on the mother’s mental health was never discussed by professionals who understood the wider case.
The report added: “Analysis confirms the view that the step down of social care services to Early Help was managed very poorly in this case. No risk assessment of any kind was conducted prior to the step down of services and no hand over of the case to Early Help was conducted.
“The social worker responsible for the case was managing a high case load and it is thought that this led to them resigning their position at the time of step down.”
Summer 2020 saw the attack on Child T.
Dr Pearson’s probe also sought to see how events unfolded from the youngster’s point of view – and offered more context on the family’s life.
Visits by social workers recorded the house being messy and “cluttered with documents”.
But records of visits by health visitors frequently failed to properly describe home conditions – something the review found would have painted a fair more comprehensive picture of how the family was living.
A 2018 report by a health visitor noted the kitchen was dirty with both children having dirty feet.
The police also disclosed that rat poison was found on the floor of one of the home’s bedrooms in 2016 – but they were not able to say whether this information was ever passed on to social care teams.
Police visits following the attack on Child T noted the house was untidy with mess scattered on the floor – and a number of dogs and other animals kept in the kitchen.
Lessons to be learned
Dr Pearson thanked professionals for fully embracing the review – and for being open and honest.
His review added the majority of them had acknowledged failings in the management of the case – something he called a “welcome and encouraging starting point”.
However, the review found the case had highlighted a number of concerning failures to keep Child T safe.
“The safest and most definitive way of providing Child T with the protection to which he was entitled, would have been to have removed him from the environment where he was exposed to the risk of further harm,” it added.
“Opportunities to take this course of action were considered a number of times but were never taken.”
A total of 11 recommendations were made in the review on the back of the “concerning failures”.
They included agencies being encouraged to professionally challenge one another on decisions, and ensuring risk assessments are carried out before critical care decisions are made which could send children home to potentially risky environments.
Regular multi-agency meetings in complex cases, closer working relationships, and more defined policies were also part of the recommendations.
A joint statement issued on behalf of members of the Hartlepool and Stockton Safeguarding Children Partnership said it fully accepted the findings of Dr Pearson’s report – adding it recognised it was important lessons were learned.
A spokesperson for the partnership added: “The agencies involved in the review have been working together closely and have already made strong progress in ensuring the recommendations and actions are implemented.
“Learning from the review has been shared with each organisation individually and also across the partnership as a whole.”