Battered baby was let down by GPS, social services and hospital staff, says damning report

THE authorities missed a host of early warning signs in the case of a Derbyshire baby left with serious injuries at the hands of its abusive father.

A serious case review into the incident involving a weeks-old toddler found there were a slew of missed opportunities for early intervention.

The baby’s father has since been charged with grievous bodily harm and imprisoned, a report by the Derby and Derbyshire Safeguarding Children Board says.

It comes after the baby – whose gender and location has not been specified to protect its identity – was hospitalised in 2017. It has now made a full recovery.

The report says there were suspicious bruises noted during hospital visits, which, for a pre-mobile baby – unable to move on their own – needed to be sensitively questioned.

The report found that further “professional curiosity” should have been carried out into these bruises and of the home situation – where there were unknown domestic abuse issues, carried out by the father.

There was a “willingness” from hospital staff to accept there were not any safeguarding concerns and vital flags could have been raised about the potential abuse, the report says. The baby was admitted to hospital three times in a matter of weeks, starting shortly after its birth.

A range of details of the case have not been disclosed, including the name, exact age and gender of the baby, the names of the parents and their specific location within Derbyshire.

The report details that the mother had a history of anxiety and low mood and had been treated with antidepressants, while the father had a history of early neglect when he was very young, a criminal record dating to his childhood and disclosed difficulties with anger and paranoia – and was in touch with mental health services.

The report found that social workers who had been referred to the couple before the baby was born – due to some known issues – were “overly optimistic” about the relationship between the parents.

It says: “There is no evidence of curious questioning around the historical concerns and vulnerabilities relating to both the father and mother.”

The completion of the assessment of the home situation before the birth of the baby was delayed, by which point the baby had been born, the report says.

It says: “This again led to an over optimistic view of how the parents would cope with a newborn baby.”

The previous issues faced by the mother and father were noted by their GPS, but the mother and father were registered to different GP practices, and the impact of these joint issues – and potential impact on a newborn baby – were not linked.

“There is no evidence that the GPS were curious to ask who the father’s partner was and where he might be registered or living,” the report says.

The mental health provider involved in the case has now ordered a review of its record keeping and how it documents potential safeguarding concerns, the report says.

It details that the Criminal Justice, Diversion and Liaison team (CJDLT), part of Derbyshire Healthcare NHS Foundation Trust (which specialises in mental health support) did make contact with the father before the birth of the child, but “did not take into account or assess what risk the father would be to his partner”.

Furthermore: “There is no information to indicate that probation or the CJDLT team was aware that the mother was pregnant, and should have assessed the risk to the mother and her baby, rather than just the risk to himself (the father).”

During the pregnancy, police were called to the home of the parents due

to a “domestic incident”, but the police were not aware or made aware that the mother was pregnant.

The mother had told police she was not pregnant, the report says.

The CJDLT also did not inform the father’s GP when he “disengaged” with their services, aimed at helping him with his mental health.

It did not provide the review with information about whether they knew the mother was pregnant or that “there was domestic abuse within the household”.

A discussion about domestic abuse was carried out when the organisation was talking over the child’s case – which had led to a Section 47 order, which means an investigation will be carried out into the child’s home life due to a reasonable suspicion of significant harm or suffering.

Once the baby was born, the report says there was a “lack of recognition” about its vulnerability.

It was brought into hospital shortly after birth for suspected bronchiolitis

– lung infection – and medical staff made note of a bruise and previous injury.

However: “The medical and nursing staff did not challenge how a previous bruise or injury was sustained by a pre-mobile baby… therefore the opportunity to challenge further or discuss with a consultant was not carried out.”

Notes of the bruise say the mark was found on the baby’s abdomen (stomach area). The mother told hospital staff it had been caused by a dog scratch, which they felt was plausible.

Five days later, the baby was readmitted to hospital but the previously-noted bruising and injury was not reviewed or investigated, the report details.

The baby’s GP had acted to ensure the hospital followed up the bruising but did not say with what urgency it should be reviewed and did not send a formal safeguarding referral.

There was also no evidence of potential safeguarding issues being noted before the baby’s discharge from hospital, which would have led to extra checks to ensure the baby would be safe at home.

The report says: “It has been identified from the review that there were missed opportunities to understand the evolution of the bruising to the baby’s abdomen, arising from the apparent presenting condition – bronchiolitis – and oversight from senior medical staff could have been stronger to ensure that changes to the nature of the bruising to a pre-mobile baby over a five-day period were identified, recorded and acted on.”

Emergency department staff at the hospital, which has not been named, have been given additional advice about safeguarding.

The report says that issues around a parent’s mental illness, other illnesses, or lifestyle issues that might impact on parenting should be alerted and linked to their child’s records – even if they are registered to different practices. This is to ensure safeguarding concerns are clear and available to under-pressure health staff.

The baby was eventually visited for a follow-up linked to the identified bruising several weeks later.

However: “There were missed opportunities regarding enquiring about domestic abuse, meaning that pertinent information about the parents’ relationship was not known.

“There is evidence from the health visitor contacts that the baby had been observed to be thriving and responding to positive interaction from their parents, suggesting that the baby’s needs were being met.

“This view did not take into account all of the other parental risk factors that were available at that time.”

The review found that agencies need to properly consider the risks posed to children by adults in their life, including cross-checks with other authorities.

It says: “There should have been more informative discussions during those early investigations and better questions asked when discussing the matter with probation and other agencies.

“The question (from probation) should not have been ‘is he at risk of re-offending?’ but ‘is he at risk to the child and mother?’

“The importance of reviewing all the information available in a thorough and structured way prior to hospital discharge is essential to ensure all the risks have been considered. Nurses should clearly document any marks or bruises seen on the ward and clearly communicate this to the paediatrician. “There was a lack of professional curiosity around the initial bruise and injury and a willingness to accept that there were no safeguarding concerns, without any proper exploration, particularly an analysis of parental mental health history.

“There were missed opportunities during the baby’s two admissions in November to recognise a potential non-accidental injury and initiate further investigations and assessment.”

The safeguarding board has given out six recommendations, including a review of pre-birth protocols, that a risk to the harm of children is noted on assessments on adults, that proactive guidance about the vulnerability of babies is given to all parents and that questions are actively being raised about domestic abuse during appointments.

The medical and nursing staff did not challenge how a previous bruise or injury was sustained. Report