By Bethany Ruby Rose And Charlotte Webster-
Social workers failed a 3 year old child by failing to A review has criticized social workers and accused them of engaging in ‘formulaic’ thinking that limited their ability to appreciate the dangers faced by a three-year-old who was killed by her mother who was drunk-driving.
The review, by the Dorset Safeguarding Children Board, found Dorset council’s children’s services’ failed in many ways to string together important pieces of information and act professionally and competently as required under the circumstances. The damning review highlights shameful failings that could have been avoided with due diligence and better co-ordinated practice.
The mother of the three year old under the care of social services had a chronic alcohol problem which should have been spotted and addressed with sensible safeguards put in place, but instead, the system was plagued by contradictions and conflicting interests that highly compromised the implementation of an effective practice. The family was highly dysfunctional and known to both police and social services.
In March 2017 Dorset Police were informed of the Father being involved in a road traffic accident where he failed to stop at the scene. The following day he made contact with the Police and admitted responsibility and was found guilty and fined. A few days later, the mother was also reported by a member of public as failing to stop at the scene of an accident, having hit a cyclist whilst driving.
The matter not being taken any further due to lack of evidence. The review stated that towards the end of March 2017 Children’s Services received an anonymous call to their Out of Hour , stating that the Mother was driving whilst under the influence of alcohol; although the referrer did not have any
immediate concerns for Child S. Records indicate that Children’s Services recognised that this information evidenced
a trail of similar historical concerns. Records state ‘threshold met and CIN assessment is needed’.
The review found that practitioners failed to make contact with Pike’s GP, the only other professional to have knowledge of her 2012 assessment for alcohol dependency.
“Consent to share information about the individual to which the information relates is not needed if there are concerns about safeguarding and promoting the welfare of children at risk of abuse or neglect,” the review said. “In this case, it seems the level of professional concern had not reached a threshold in order to dispense with consent; the weight of information did not appear to support greater intervention.”
The review stated that an approach to risk-assessing Louisa Pike’s situation “appeared not to deviate” despite increasing numbers of referrals involving her mother Alanda Pike.
“Opportunities were available to children’s service however, the presenting concerns were never judged as being at a sufficient level to warrant a more joined up and holistic approach,” the review said. Pike is currently serving a custodial sentence of six years imprisonment, commencing from October 2017, after being found guilty of causing death by dangerous driving after pulling into the path of a van, while under the influence of both alcohol and cocaine, and with young Louisa in her backseat.
She had been assessed as “moderately to severely dependent on alcohol” in 2012, but this was unknown to professionals later involved with her, because she hid the information from them. Although concealed, a highly efficient and well co-ordinated system should have discovered it because the information was available in the system. The review stressed the need for more effective multi-agency working around families where alcohol or substance misuse were “dominant features”.
BANNED
The review found that whilst 13 weeks pregnant with Louisa, Pike had been banned from driving for 30 months after being stopped while four times over the legal limit. Shortly after the child’s birth in 2014, children’s services received an anonymous referral relating to alcohol and cocaine use in the family home. But this was closed as a “desk-based assessment” after contact with midwives and health visitors. In June 2016 Dorset Police received an anonymous call regarding the Mother driving a vehicle whilst suspected being intoxicated.
However, the matter was not investigated until August 2016. In October 2016 Dorset Police received information linking the Mother with other third parties who were misusing. In April 2016, police were called to a supermarket in Hampshire after Pike dropped Louisa while intoxicated, leading to a children’s services referral. The case was closed after 19 days because of “a lack of corroborating evidence to support any ongoing risk”.
In the spring 2017, in the months leading up to Louisa’s death in August, social workers investigated further reports of Pike being intoxicated, and on occasion driving under the influence. Children’s services eventually recognized a pattern of concerns, and recorded the need to start a section 47 investigation.The cases were closed after home visits revealed no alcohol , and found Louisa seemed “happy and talkative”. On each occasion, pre-school staff and health visitors raised no concerns about her welfare or Pike’s parenting capacity.
The serious case review noted that while children’s services conducted child in need assessments on at least four occasions, “information from other agencies continued to conflict” with concerns.
“With the benefit of hindsight, this review is now able to piece together several strands of information, which had they been known and triangulated at the time would have likely resulted in a different approach to any formal assessments undertaken,” it added.
Crucially, the review found, practitioners failed to make contact with Pike’s GP, the only other professional to have knowledge of her 2012 assessment for alcohol dependency.
“Consent to share information about the individual to which the information relates is not needed if there are concerns about safeguarding and promoting the welfare of children at risk of abuse or neglect,” the review said. “In this case, it seems the level of professional concern had not reached a threshold in order to dispense with consent; the weight of information did not appear to support greater intervention.”
Reiterating the benefit of hindsight, the review added that the “more robust route” of a child protection investigation would have been beneficial in gathering information and making multi-agency decisions.
“Seeking information from new sources to either confirm or disprove any hypothesis formed is not unreasonable given the escalating number of episodes where the mother was reported to be using alcohol,” it said.
CHALLENGES
The report said that Louisa’s death had highlighted the “inherent challenges for professionals when working with parents who use, and misuse, alcohol”.The review found that there had been “little emphasis” within Dorset’s safeguarding training on parental alcohol use, and its potential risks to children.In common with some other recent serious case reviews, the report also noted that Louisa’s father had been insufficiently involved in safeguarding enquiries.
“He would have been involved in the handover of care to the mother, and in an ideal position to comment on whether [she] had been drinking or not,” it said. “It is also noteworthy that the father was responsible for making at least two referrals to the police expressing concerns about the mother driving while intoxicated.”
It also said that an unnamed local public protection forum, which the review found had challenged Dorset’s decision to close one of its cases, should be guaranteed a “mechanism to check the progress of single agency actions”.In a statement issued by Dorset council, Steve Butler, cabinet member for safeguarding said the council was “committed to learning from this case and working with other agencies to reduce the risk of a similar tragedy happening again”.
“We are never complacent and are focused on improving the way we, and our partners, share and use information to protect children,” Butler said.
He added that Dorset’s introduction of a multi-agency safeguarding hub (MASH) had addressed some of the issues identified by the serious case review, and that midwives were now expected to gather more information relating to women in the early stages of pregnancy.
Sarah Elliott, the independent chair of the Dorset Safeguarding Children Board said the case showed that “key links were not being made” despite the involvement of professionals with Louisa’s family.
“It really does bring home the need for professionals to be curious and share information with one another, so they can consider the whole picture to help keep children safe,” Elliott added.
Both authors named above contributed to the writing and presentation of this article