Social workers failed to act to protect a vulnerable child less than three weeks before she was hospitalized with a broken arm, despite warnings that she was being neglected and at risk of injury, an inquest report has concluded.
A review found that health visitors and social workers repeatedly delayed intervention during months of mounting evidence that the girl was experiencing physical and emotional trauma and her parents were failing miserably to care for her.
The girl was chronically underweight, left for hours in dirty diapers, slept in a bare bed in the middle of winter, was socially isolated and never spent time with other children, had no toys and was presented as “sad, watchful and frozen,” the report said. .
“The family environment in which [the child] spent the first 17 months of life can be described as a time of chronic neglect, fear, under-stimulation, discomfort, loneliness and physical harm,” the review of child protection practices found. childhood.
Northamptonshire Safeguarding Children Partnership, which carried out the investigation, said professionals failed to act decisively on the reams of evidence they had amassed, leaving the girl exposed to months of significant harm and neglect .
“If there is an important and resounding lesson to be learned from this review, it is that it is not enough for professionals to observe and record the signs of neglect and abuse. Action is needed if children are to be protected from significant harm,” he concluded.
Medical visitors had become concerned about the girl’s growth and development soon after she was born. Although they noted that the mother had mental health issues, lacked attachment to her daughter, and could be hostile and evasive, they did not refer the case to child protection teams for more than a month. a year.
When social workers finally got involved in September 2018, there were further delays and drifts, and the situation came to a head shortly before Christmas that year when an engineer sent to fix a boiler sounded the alarm. after seeing the girl in a bed with her arms up. tied to her sides with electric wire and surrounded by used diapers.
Social workers visited the family again, but despite clear signs things were not going well, they did not ask about the registration of the girl’s arms. They decided not to escalate the matter, instead leaving his parents with instructions “on what to change” in their parenting methods to keep the child safe over the holiday period.
Reflecting on the decision not to intervene, the inquest report states: “In light of the overwhelming evidence of neglect, the failure to take immediate action by children’s social services to initiate child protection proceedings childhood raises serious questions of professional judgment.
In January 2019, the child was admitted to hospital in agony, three days after her parents reported to social workers that the girl had a swollen arm. X-rays revealed a broken arm, as well as multiple historic leg fractures. She was immediately placed under police protection and her parents arrested.
Social workers had not failed to know of the potential risks to the girl, the inquest found. There was, however, a lack of “management control”, which, coupled with frequent changes of social workers over the three months of their involvement, resulted in the girl suffering significant harm.
Asked by the survey why they had not referred the girl to child protection sooner, the health visitors said, based on previous experience, that they believed the intervention thresholds of child protection were set so high that their reference would inevitably be rejected.
The young girl remains in care and, according to the Northamptonshire Safeguarding Children Partnership, “is starting to thrive with her foster families”. His parents, Sarah Elizabeth Cunnington and Ryan Eames, were each jailed for two years and seven months in October 2021.