By James Simons-
Social workers from Kent Council failed the a baby who died from a brain injury, and failed the family too.
A recently published serious case review has concluded that social workers at Kent Council could have done more to “explore and challenge” neglect the dead baby and his siblings experienced at home.
The review states that it does not focus solely on the critical incident which sparked the review; but seeks to learn from the whole case and the way in which agencies have worked with the family and worked together to identify and mitigate any risks to children up to the critical incident. The review describes its aim as being to draw on a systemic and causal analysis to understand the dynamics of the helping relationships with the child. It also aims to apply any lessons learnt to
changes may be needed in local systems to improve responses in future, similar cases.
However, it highlights the huge failing of social services in handling the case of five-month-old Eli Cox, from Kent, found by a post-mortem to have sustained 28 fractures in the weeks leading up to his death in April 2016. He and most of his six siblings had been stepped down from child protection plans just two months earlier. Eli’s mother Katherine Cox, and her partner Danny Shepherd, were convicted last November for causing or allowing the infant’s death. The serious case review set out to examine the context of “neglectful and chaotic” parenting surrounding Eli‘s short life, which it noted had been an “important background factor” in similar cases involving physical assault. The review, for Kent Safeguarding Children Board concluded that professionals involved with the family, known to social services for over a decade, were sometimes “overly optimistic” when presented with small signs of improvement.
The review said it highlighted the dangers of ‘disguised compliance’ by parents – which in the case of Eli’s family was “thought about but not really tested”. The review, which acknowledged the difficulties of working with large families, also said social workers’ supervision was “inconsistent” and “not in line with policy”.Nonetheless, it concluded there was “no evidence to suggest any professional working with the family saw or could have seen any indication of the violence experienced by [Eli]”.
Kent council children’s services had been intermittently involved with Eli’s family since 2005. Support they provided to the family revolved around poor home conditions and associated issues like domestic abuse and drug and alcohol misuse. The mother had reportedly been exposed to both from an early age – and budgeting. Alarm was raised by the children’s school, who made several referrals because of fears about their development, appearance and personal hygiene, while the police also regularly raised concerns. Those referrals were sometimes escalated, but other times deescalated whilst all of Eli’s siblings were being made subject to child protection plans for neglect in January 2015.
During the first half of 2015, police were repeatedly called to domestic abuse incidents – perpetrated by both parents – at the family home.
The review revealed that at school the children were “seen as guarded and possibly advised not to talk about home”. There were “several reports” of the children having injuries, one of which was feared to be non-accidental and resulted in a hospital visit. Plans were being made for more intensive work with the parents, and by the first half of 2015, police were repeatedly being called to domestic abuse incidents perpetrated by both parents. Cox separated from the child’s father two months after her pregnancy was discovered, and had a new partner called Shepherd. He was joined in the household by a lodger, his cousin, whose addition to an already overcrowded house was deemed a “concern”. The review pointed out how alarms were raised during the autumn around sexualised behaviour by the children, yet not pursued. Frequent bruising was also seen on Jude, Eli’s two-year-old brother, believed to be caused by poor supervision but put down by Cox to clumsiness.
“The children were seen at school, as mother would not let the social worker visit at home,” the review added. “The children reported that things were fine at home, but there was a suspicion they were being coached in what to say.” The review revealed that by early February 2016, when a child protection review conference was held, matters were believed to have improved, leading to all the siblings except Jude were stepped down to ‘child in need’ level. The decision to step them all down to ‘child in need level’ was applied to young Eli to the displeasure of most professionals. Eli had been subject to a child protection plan from birth. Police were called to one incidence of drunkenness in March social workers continued to observe apparent improvements, with Eli happy and “receiving appropriate care and stimulation”. A few weeks later, he was dead.
The review highlighted a number of shortcomings that had arisen during practitioners’ dealings with Eli’s family. It included challenges caused by the number of children involved, combined with poor coordination between agencies, all leading to complicated, time-consuming contacts with the family. The review also found an apparent tendency for professionals to see the siblings as a group, not individuals.
Social worker’s reports to child protection conferences were also inadequate, as they made references to other practitioners’ observations, as well as that of the social worker. They incompetently sought to provide a pen picture for each child,” the review said. “But these do not include a thorough-enough assessment of each child’s overall emotional and general development.” The review also criticised an apparent failure to explore whether the children, who “idolised” their mother were showing signs of chronic neglect.
It also emerged that some workers also lacked confidence around assessing significant harm and working with disguised compliance, while others felt it was hard to challenge social workers’ opinions in multi-agency settings. “A question arises about the possibility of ‘groupthink’ influencing practitioners who feel less confident,” the review said. Overall, the serious case review found there was “not enough challenge and scepticism about [Cox’s] capacity to change and sustain change”, especially given the family’s history.
It added: “There was a view that mother knew how to keep workers at bay and what to say to please them. Disguised compliance was thought about, but not tested out or robustly challenged.”
Men remained indistinct figures in the narrative, with Eli’s father successfully “absenting himself” from child protection procedures while Shepherd was an “unknown quantity” who should have been made part of assessments and reviews.
On the part of two social work staff involved with Eli’s family, “inconsistent” supervision carried out by separate managers hampered coordination, the review concluded. “The two workers had regular conversations and shared information about their progress,” it said. “This does not, however, replace reflective questioning and advice by a third party as a ‘critical friend’ to challenge and inform the continual reassessment and proposed actions.”
Among a series of recommendations, the review called for audits to ensure parents’ and carers’ capacity to change was properly assessed, and for strengthening of arrangements to consider children’s emotional development.
It said Kent’s safeguarding children board should review how frontline workers and their managers were equipped to engage with “challenging” parents and carers around domestic abuse, as well as agencies’ supervision procedures. Responding to the review, Gill Rigg, the independent chair of Kent Safeguarding Children Board, said all relevant partner organisations had now drawn up “individual action plans for improving the way they continue to work to protect children in the future”.
A Kent council spokesperson admitted there were important lessons for everyone to learn when working together to support complex families with multiple risks and challenges”.
The spokesperson added: “The review process has identified a number of areas in our own practice we can improve, and we have worked very hard to provide better support and challenge to families such as these.”