A serious case review in Kirklees following the death of a two-year-old girl has concluded she was ‘largely invisible’ to staff addressing the needs of others in the family.
In May 2008, ambulance staff in Kirklees were called after the mother reported that she had found her daughter in the bath under water.
The post-mortem found no evidence of drowning and Sanam Navsarka was found to have multiple injuries, some of which were a month old.
The mother, Zahbeena Navsarka, was convicted of manslaughter and her partner, Subhan Anwar, is now serving a minimum term of 23 years for murder.
According to the report: “Despite a raft of agency involvement the child was not the focus of intervention, which was instead directed towards the adults, or towards other young people within the family for whom staff had a particular responsibility. She is largely invisible in this review.”
Three members of staff have been the subject of disciplinary investigations as a result of their involvement, two of whom have received sanctions.
The review involved the different agencies involved in the case: Kirklees Safeguarding Children Board, Kirklees Council, Kirklees PCT, Calderdale & Huddersfield NHS Foundation Trust and West Yorkshire Police
The conclusions include:
- The child should be clearly visible (paramount) in any intervention. That is, the child should be the focus of assessment and intervention
- Assessments should focus on the child and take account of the three domains of the Assessment Framework
- Pre-birth assessments should be undertaken at least 12 weeks before birth.
- Regular supervision is essential to maintain a child focus and identify areas of concern
- Accurate case recording is essential to aid good practice
- Professionals in Fostering and Residential have a responsibility for child protection in respect of all children
Karen Hemsworth, vice chair of Kirklees Safeguarding Children Board and assistant director for Safeguarding Children and Vulnerable Adults, NHS Kirklees said the agencies were already acting on the recommendations.
“While the review finds that agencies acted appropriately in identifying and providing services to the mother, it is clear that there were faults in the recording of concerns about Sanam’s welfare.
“We are taking steps to ensure robust systems are in place to better monitor supervision and to improve the competency of all staff in child protection issues.”
See the links on the right for the full serious case review and statements.