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'Basic' partnership working contributed to child death

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A baby that died and three others that were seriously injured were let down by Sunderland City Council’s children’s services and other professionals, a series of reports have found.

A report into the findings of three serious case reviews, commissioned by the Sunderland Safeguarding Children Board, found no “endemic and systemic failure”, but highlighted a poorly managed workforce under considerable pressure. 

The report, by Dr Mark Peel and Dr Trish Shorrock, said the partnership between agencies at the time of the incidents, which took place between 2012 and 2015, worked only at a “basic and pragmatic” level and there was a rapid turnover and poor retention of social workers.

Other problems identified included poor communication between agencies, low quality assessments of risk and failures to listen to the children involved.

Baby E, whose parents had a history of alcohol and drug misuse, died aged 4 months after being found unresponsive at her home in September 2013. The cause of death could not be ascertained.

The family had been known to agencies for a number of years, but none of the four children were the subject of child protection or child in need plans, although concerns were raised by frontline staff and child in need plans were offered.

Baby O was taken to hospital when she was six months old in August 2013 suffering from a broken leg and bruising to her face, back and legs which were deemed non-accidental.

Her mother had become seriously ill soon after the baby was born and she suffered the injuries while being looked after by her grandmother, who was subsequently convicted of child cruelty.

The serious case review found a pattern of neglectful parenting was not consistently monitored and the threshold for intervention by children’s services was high.

The report also found the safeguarding board failed to challenge and escalate children’s services inaction.

Baby W was 11 weeks old when he was admitted to hospital in 2012 and found to have sustained a fractured skull which was deemed non-accidental. The cause of the injury has not been ascertained.

The baby was subsequently placed with foster carers, but the case was not referred to the safeguarding board by children’s services as required.

The serious case review found there was poor managerial oversight of previous assessments of the child and his older sibling and a lack of effective coordination between agencies.

A fourth serious case review into injuries sustained by Baby G is yet to be published as the case is the subject of an ongoing investigation.

Responding to the report, Jane Held, independent chair of the safeguarding board, said: “Sadly, these babies and their families were not always served well by the professionals and agencies responsible for supporting them.

“These included the NHS, early years services, education services, the police and children’s social care.

“We let these babies and their families down. This is something we deeply and profoundly regret and we apologise unreservedly to all those involved.”

An Ofsted report in July last year revealed a “corporate failure” by senior leaders and managers in the city that left vulnerable children and young people unsafe.

Sunderland MBC chief executive Dave Smith resigned from the council three months after the report was published and Nick Whitfield, Kingston upon Thames RBC and Richmond upon Thames LBC joint director of children’s services, was appointed by the government as an independent commissioner to oversee improvements in children’s services.

Children’s services in the city are now being transferred to a new organisation independent of the council.

Ofsted inspectors noted improvements had been made after their first monitoring visit in August, the findings of which were published on 3 September.


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