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Somerset Serious Case Review calls for better understanding

Following injuries sustained by two Somerset babies a Serious Case Review by the Somerset Safeguarding and Care Board has highlighted an ‘over optimistic’ attitude and over reliance on the word of parents who appearing concerned and cooperative. It comes barely 18 months since a similar review into the case of the non-accidental injury of a Somerset child “Y” in 2013.

So are we back to square one with an underperforming Children’s Services department? Not necessarily. Many of the problems highlighted in the Child Y review involved poor communication both within social worker teams, and between agencies such as midwifery, police, social care etc.

In this case the main problems identified were mostly different:

•           Understanding and reviewing family history

The parents in this case both had significant issues in their past including domestic abuse and mental health problems associated with the misuse of drugs. Helpful information about the parents could have been obtained if housing association staff had been invited to participate in case planning meetings.

•           Over reliance on the word of the parents

The review also observed that professionals should have been more sceptical of the explanations given by the parents and taken the opportunities to corroborate what they were saying. The chaotic lives of the family sometimes diverted attention of professionals.

•           A greater understanding of normal child development

Child J was only five months old when it sustained a cut to the inside of their upper lip in April 2014. A child of this age was unlikely to have acquired such an injury by accident and police and social care staff should have been more suspicious of this being a non-accidental injury.

However it is more disturbing to note that in some areas lessons have clearly not been learned from the Child Y case.  That case highlighted the importance of GPs and other health professionals identifying the role and impact of fathers on the ability of mothers to safely parent, and sharing information about fathers where background or historical concerns exist. In other words understanding and reviewing family history.

And once again we are told of the need for “better sharing of information between agencies, more face-to-face meetings and better management supervision.” This does sound to me like a lesson that is not being learned.

It is of course easy to pick on these reviews when they occur and assume the worst. It is worth noting that the review also noted examples of good professional practice, including:

The GP raising concerns about Child J, having noticed bruising

The housing support worker providing continuing of care to the mother of Child L and Child J

The health visiting service for maintaining a relationship and responding flexibly to the needs of the family and including the male partner and father to Child J

We do know that their have been significant improvements to the Children’s Services team. A new director has been in place for a couple of years, recruitment has improved and staff turnover and case load issues addressed.

But some lessons still need to be learned 18 months after the last time we were told they needed to be learned. That is disappointing and not something we would hope to see again in the future. “All the agencies have contributed to this review and are committed to learning the lessons that come from it,” says Julian Wooster, Somerset County Council’s Director of Children’s Services.

To date there has been no prosecution in connection with this case and the children are now living under special guardianship.

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