Gloucestershire council’s children’s services have a “complete lack of a child focus”, according to a serious case review into the circumstances that led to a three-year-old boy being taken to hospital with bruising, fractured ribs and a perforated intestine.
The child, who survived and is named in the review as “Philip”, had been known to Gloucestershire’s child protection team for 16 months when he sustained the life-threatening injuries, which were assessed as non-accidental.
The partner of Philip’s mother was jailed for three years after being convicted of grievous bodily harm. The mother was given a 12-month suspended sentence on a different charge.
Jane Wiffin, the author of the review, said there had been been an “unacceptable delay” in contacting Philip’s mother after his first nursery raised concerns about bruising with the child protection team.
The review also identified “very poor assessment practices by the individual social worker” and “inexperience regarding assessment of physical abuse”. The review criticised poor inter-agency working and inconsistent sharing of information which meant that some health services were abreast of Philip’s situation as his health deteriorated, but others knew nothing. Even when information was shared between his GP and nursery, it was “not used to make sense of any of the children’s circumstances”.
The fact that Philip was not medically examined when first referred, despite having 25 or more bruises, was “one of the most troubling aspects of this incident”, Wiffin said. “Given the number of bruises, regardless of the cause, this young child should have been medically examined. Mother was not asked by any agency involved to take him to the GP and she did not do so.”
A later referral about even more extensive bruising resulted in Philip being examined by a paediatrician but the assessment of physical abuse was described by the review as poor and unclear. Despite the paediatrician’s belief that there was no medical cause for the injuries and that they remained unexplained, Philip was allowed to go home. The family’s social worker did not see him again for almost a month.
Throughout the review, it is observed that children’s services staff appeared to rely heavily on the mother’s account of Philip’s injuries, meaning early opportunities to safeguard Philip were missed.
Philip lost 1.5kg in weight, a significant loss for a child of his age, and there were further concerns about neglect in his wider sibling group, which were discussed by a number of agencies, the review found. Philip was admitted to hospital with life-threatening injuries after his mother called an ambulance saying he had been vomiting for four days.
The review follows the publication of a string of searing judgments by the family court which have criticised Gloucestershire’s children’s services department for its failings, including repeated delays, poor evidence gathering, case mismanagement and wasting of public money, all to the detriment of children in their care.
There have been 26 serious case reviews published in England in 2016 but Gloucestershire is the only local authority to have been the subject of three.
Kathy O’Mahony, the director of children’s safeguarding at Gloucestershire county council, said: “The review highlights the efforts that were made to work alongside the family, but also that procedures were not always properly followed. The young boy has made a recovery and is safe and well with his family. We continue to reinforce with all of our staff the importance of taking early and robust protective action, and we regret this did not always happen as it should have in this case.
“There has been a thorough internal investigation and management action has been taken where necessary. It is important that we act when we need to improve, but also recognise the significant amount of good work social workers and family support staff do every day.”
Dave McCallum, the independent chair of the Gloucestershire safeguarding children board, said: “It is clear that there were failings by the professionals that came into contact with Philip, and that best practice was not followed. Since Philip suffered the injuries, the board has driven considerable work to reinforce with professionals the importance of child-focused practice and the need for professionals to challenge information.”
