‘Warning signs missed’ over Derbyshire baby left hospitalised by abusive dad
An investigation into the significant harm caused to a Derbyshire baby by its abusive father has found that authorities missed numerous early warning signs.
The serious case review looked into the incident in which a Derbyshire baby only a few weeks old was left with serious injuries and hospitalised in 2017.
Fortunately, the baby has made a full recovery.
The father of the baby, who caused the significant injuries, was charged with grievous bodily harm and was imprisoned.
However, the report, carried out by the Derby and Derbyshire Safeguarding Children Board, has found that authorities missed several chances for early intervention.
This includes suspicious bruises noted at hospital visits, which, for a pre-mobile baby – unable to move on their own – are to be sensitively questioned by professionals.
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. He was also in touch with mental health services.
The report 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.
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.
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 CJDLT were 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 Section 47 order.
A Section 47 order 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 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.
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.”
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.
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.