The death of Baby P. (grim details
here) was shocking in the level of violence inflicted, but in the UK there
are unfortunately plenty of fractured families where children face potential
harm.
Here in Bristol, the body collectively responsible on our behalf for the
protection (safeguarding) of children is the
Bristol Safeguarding Children Board (BSCB). Looking at the
Council's Key Performance Indicators for Children and Young People's Services,
there are 274 children with
Child Protection Plans (i.e. they are "at risk") and the parent(s) of 16 of
those are on their second plan.
Where a child has died the anonymised
serious case reviews are made available via the council. Let's have a look
at a few extracts from the report on the death of "Baby Z". I'm not going to add
any commentary, but I will offer you the report's conclusions first:
Conclusions [of the Serious Case Review]
Family situations involving parental substance
misuse are complex and require co-ordinated assessment and activity,
particularly as situations may change quickly. Relapse, particularly in the
early stages of treatment, is likely.
Through her journey from chaotic drug use,
into structured treatment, and then relapse, SZ appears to have been open with
agencies as to her needs and issues. For those families who do not come within
the threshold of child protection concerns, the co-ordinating processes between
adult and child-focused services do not seem to be in place, as they are when
child protection processes have been invoked. There are various points in this
case, particularly where it was recognised that SZ was relapsing, where greater
multi-agency working may have pulled children's social care in sooner, or kept
them involved for a longer period.
Baby Z’s death was clearly avoidable, but the
information considered by the panel does not indicate that any agency could have
reasonably known that he was at risk of methadone ingestion, and at this point
it is still unclear as to how he came to ingest it. There is no suggestion in
this report that there was any failure in the inter-agency child protection
system contributing to the death of Baby Z.
That was the conclusion. Now here's the detail.
Reason for this Serious Case Review
Baby Z
died at home on 21st July 2007, aged 14 months, whilst in the care of his mother
SZ, and her friend X. Both SZ and X have a history of drug misuse. When police
attended they found evidence of drug taking, including spilt methadone. The
cause of Baby Z's death is recorded as ‘morphine and methadone intoxication’. SZ
was charged with manslaughter and was remanded in custody shortly afterwards.
She pleaded guilty and received a 5-year prison sentence at Bristol Crown Court
on 26th June 2008. [...]
Mother (SZ)
SZ was 29 years old when she gave birth to Baby Z. She had been
known to social care services during her adolescence relating to concerns about
her offending behaviour and drug use. In her adult life, SZ’s drug use continued
to escalate, with her injecting both heroin and crack. She was also very
vulnerable in terms of selling sex to fund this drug use. She received support
and monitoring from several organisations, including Probation and drugs
services. [...]
In November 2005, the Probation service and
hospital became aware that SZ was pregnant and a referral was made to the
specialist drug service. SZ commenced a treatment programme and accessed daily
dispensing of methadone. A Pre-Birth Initial Assessment was completed by a
Social Worker in liaison with other agencies. SZ attended all of her antenatal
appointments, supporting the assessment that her drug use had stabilised and she
was well motivated to change her drug using behaviour because of the impending
birth of her child. She was described as “doing amazingly well.”
When Baby Z was born in hospital in May 2006,
he was admitted for observation and treatment for methadone withdrawal. SZ and
Baby Z were discharged from hospital 3 weeks later to temporary accommodation.
SZ continued to remain stable on her methadone prescription and continued to see
her Probation Officer. [I]n July 2006, SZ started a new relationship with AW,
but shortly afterwards he was diagnosed with cancer. [...]
In September 2006 a referral was made to
children's social care from the hospital where AW was being treated as an
inpatient for cancer. AW was observed to pick Baby Z up by the ankle and ‘swing
him’ onto the bed. An Initial Assessment was completed by a Social Worker
following a home visit to SZ and Baby Z. A very warm relationship between them
was observed. AW's handling of Baby Z was assessed as being a result of his own
limited
mobility. [...]
Between January 2007 and April 2007 there were
a number of indicators held within individual agencies that SZ was starting to
get into difficulties. From an individual agency perspective those indicators
were not followed up or shared with all the other agencies. If they had been, a
collective picture may have emerged which would have indicated a higher level of
concern. The presence of SZ and Baby Z during a police execution of a Drugs
Warrant also presented a missed opportunity to link up increasing concerns about
what was happening. [...]
In May 2007, the specialist drug service
became concerned due to SZ missing appointments and her admission that she had
returned to using crack and heroin on top of her methadone. A referral was made
to children's social care and the GP and Health visitor were informed. As a
result, a joint visit was made by a children and families Social Worker and the
Health Visitor. The Social Worker felt that SZ was committed to getting back on
track with her methadone programme. The home environment appeared clean, and
Baby Z looked well cared for. The conclusion was that there were no immediate
concerns for Baby Z’s welfare and that the Health Visitor would provide enhanced
visits to monitor the situation.
In June 2007, SZ reported to the drugs worker
that she was pregnant and suffering from morning sickness. She requested daily
pick up of methadone, rather than supervised consumption. This was agreed as
clinically appropriate. Her pregnancy was not reported to children's social
care. [...]
Father (KZ)
There is little information in agency records on KZ. He has a
history of criminal convictions going back to 1999 and appears to have had
limited contact with his son. He is currently in HMP Dartmoor having been
recalled on a Drug Treatment and Testing Order.
Full report
here, along with those for "Family
W", "Baby
X" and "Child
A" the last of which in particular I wish I could "unread".
James Barlow
