Lucy

Apr 23, 2022

Neglected toddler seriously injured after falling out of 20ft-high bedroom window 'Lucy' suffered from 'lower level neglect' throughout her life and was 'seriously injured' as a result of the accident 06:00, 23 APR 2022 Get the latest news from Darlington direct to your inbox with our free email newsletter Something went wrong, please try again later.Invalid Email Subscribe We use your sign-up to provide content in ways you've consented to and to improve our understanding of you. This may include adverts from us and 3rd parties based on our understanding. You can unsubscribe at any time. More info Thank you for subscribing!We have more newsletters Show me See our privacy notice A toddler was seriously injured after she fell out of a 20ft-high bedroom window, a review has found. An ambulance was called out in July 2020 after a two-year-old girl, referred to as ‘Lucy’, fell out of the window at her aunt’s house. A child safeguarding practice review, previously known as a serious case review, found that she suffered from “lower level neglect” throughout her life and was “seriously injured” as a result of the accident. Lucy’s situation was exacerbated by the covid pandemic as she was not seen by professionals, including a health visitor or social worker, inside her home between the start of the first lockdown in March 2020 and her accident in July 2020. Her mother, who was eighteen when she gave birth was often hard to "pin down", according to the report. Following an Ofsted inspection in December 2019, Middlesbrough’s children’s social care services were rated as “inadequate”. A monitoring visit by the watchdog in December 2021, found that “stronger practice” is in place but too many children still face delays meaning some remain in inadequate situations for too long. Lucy’s mother had been in care since she was seven years old after being neglected by her own parents. According to the report, she had a large number of care placements and there was involvement from the police and youth offending service (YOS). There were also periods of time when she was missing from her placements. Lucy’s mum had a history of depression and self-harm though they were not thought to be an issue by the time her daughter was born. The review did criticise professionals for not considering the impact of her anxiety on her ability to parent Lucy. By the time she was pregnant, she had reconciled with her mother and was living in the family home. One of the first failures associated with Lucy’s case was the lack of action after a pre-birth referral from the midwife during the pregnancy. Unborn baby procedures state “that an assessment will take place ‘where the expectant parents are currently active to children’s social care and/or they have children who are currently active to children’s social care’ and because of the specific vulnerabilities that the midwife outlined,” according to the report. The review goes on to add: “Lucy’s mother was receiving a service from Pathways as a care leaver and therefore technically open to children’s social care so a pre-birth assessment needed to be considered, or at least there should have been a clearly recorded reason why the procedures were not being followed which was shared with other professionals. Read More Related Articles “There is no evidence that the midwifery service challenged the decision.” A single assessment was carried out after the Pathways worker made a new referral around a month later, raising concerns about drug misuse, lack of settled accommodation, domestic abuse in the relationship, and concerns about Lucy’s mum being able to care for her. Following this, it was decided that Lucy would need to be on a child in need plan following birth. The review states there needs to be clarity over the roles of all professionals involved with the family, as there were assumptions that the Pathways worker was responsible for Lucy when this was not the case, as she was there to support her mother. ‘GP checks had not been undertaken’ There were concerns about Lucy’s parents' relationship prior to her birth. Professionals involved accepted Lucy's mother’s comments about her dad without attempting to meaningfully engage with him over the child in need plan before his daughter’s birth or later when a new plan was made, according to the report. However, he did appear to have contact with Lucy once she was born, and despite "some ongoing difficulties" regarding social media comments, it was said to be mostly positive by Lucy’s mum. The report adds: “At one stage, when Lucy’s mother had housing issues, Lucy went to stay with her father and his parents. “There was still no attempt to undertake a proper assessment of him, to involve him in the child in need plans, or to consider what help and support his side of the family could provide to Lucy.” Information about Lucy’s dad suffering from neglect during early childhood slipped through the cracks and it was not known to the professionals working on Lucy’s case that he had been known to children’s social care. The review adds: “This was not known to those currently working the case, as it appears that GP checks had not been undertaken. This information should also have been available to children’s social care but changes of IT system seem to have led to it not being readily available. Father was also known to the youth offending service, but these checks were not undertaken.” Lucy’s dad is now her full-time carer, however, he told the review that during her first years he knew little about any professional involvement with his daughter and was not invited to be involved in any planning. There is currently work being undertaken nationally on how better to involve fathers in the lives of their children. ‘The risk from neglect was not identified’ According to the review, despite Lucy suffering “from lower level neglect throughout her life… the risk from neglect was not identified at the time”. The report states: “A second single assessment was completed when she was around a year old following allegations shared by a family member about the home conditions at maternal grandmother’s home, where Lucy and her mother were living. “Concerns were also shared about maternal grandmother’s alleged long-term and ongoing misuse of amphetamines. No further action was taken by children’s social care following the assessment and again it was recorded that due to the Pathway’s worker and health visitor involvement there was no need for social work involvement with Lucy.” This was not challenged by the Pathways worker or by the health visitor, according to the review. ‘A defensive rather than open-minded review’ An audit of Lucy’s case was undertaken in May 2020, where it was identified that Lucy’s mother had been missing appointments, not engaging with professionals and dismissing concerns. It suggested that Lucy’s case should have a child protection focus rather than a child in need focus and a strategy meeting was held. However, the social workers reviewing the case did not believe the threshold for child protection had been reached and they believed that the auditors’ thresholds were lower than what was expected in the area. The report adds: “This was despite the external audit team being asked to consider thresholds locally and a view from Ofsted that this was required.” A child protection plan is more serious than a child in need plan and provides more intensive support. It is implemented for children who are thought to be suffering, or likely to suffer, from significant harm. Despite the team’s suggestion of a children protection focus, the strategy meeting concluded that a child in need plan was still appropriate, however, it was agreed that the plan must be “really strong”, though it is not clear what that entailed. The review claims that professionals at the strategy meeting were “over-optimistic” about how safe the environment was that Lucy was in. According to the report, it is difficult for professionals to change their mind when they have decided on a course of action without there being any “significant incident” or “clear changes” in the situation that leads them to reassess. The report added: “The audit led to a defensive rather than open-minded review of the case.” At the December 2021 monitoring visit of children’s social services, Ofsted said that senior managers are more directly involved in cases and the auditing process was described as a “particular strength” which provides “in-depth coverage of the quality of services”. ‘Challenge to pin down’ In the two months after the audit and the strategy meeting in May 2020, the social worker who was assigned Lucy’s case only saw her and her mother once. This meeting took place outside of the home, for a short period, and planned work couldn’t be completed due to confidentiality issues and lack of time. From the outbreak of the covid pandemic and the first lockdown in March 2020 to the accident in July 2020, there were no visits inside Lucy’s home. According to the report, this was a result of them living in a temporary supported housing unit with other residents. Health visitors were instructed to not have face-to-face visits with people until they received appropriate PPE, which didn’t arrive for around three weeks. Then, they could only do face-to-face visits with “new birth contacts, those on a child protection plan or if there was an absolute clinical need, where visits had to be authorised by service manager”. Lucy and her mother did not match the criteria as she was on a child in need plan. At the strategy meeting on May 19, it was agreed that the health visitor should visit but two weeks later the health visitor became unwell and was then on extended sick leave. Lucy’s mother became even less engaged during the pandemic as it was easier to avoid professionals and “superficially” engage on the phone or when meeting for a short time outside. Professionals did try to see Lucy and her mother but these attempts were not always successful. While Lucy’s mum came across as managing well at child in need meetings, which were conducted via phone in April, May and June 2020, and there was a generally positive view of the situation, there was no evidence that this was actually the case. The review adds: “There is little evidence however of much direct contact with either Lucy or her mother at this time to justify the positive picture.” The health visitor was not able to join the child in need meetings due to connection and call quality issues. Middlesbrough Council did buy WEBEX licenses to use for meetings, but these were prioritised for child protection meetings, meaning that social workers organising child in need meetings did not have easy access. The report states that this situation was improving at the time of the review. The professionals working on Lucy’s case said that her mother could be a “challenge to pin down and that it was often hard to speak to or see her”. The report states that professional expectations can adjust where care leavers are concerned and that can lead to excuses being made for them missing appointments, difficulties in accepting support and negative attitudes towards professionals. 'Those involved at the time were not aware of the child’s lived experience' There was also a lack of a timeline regarding Lucy’s case. This is important as it would have included all multi-agency information so there would have been a full picture of her care over time and persistent harms might have been identified. If this was in place, Lucy’s mum’s poor engagement with professionals and the number of missed appointments might have been picked up. A full chronology was not carried out until after her accident when the local authority began care proceedings. The report adds: “During the review, there remained optimism about how engaged Lucy’s mother had been, despite evidence available to the review that this was not actually the case. “Those involved at the time were not aware of the child’s lived experience over the months of the first lockdown as they had minimal contact with her and her mother. The contacts that did happen were for a maximum of 15 minutes and were undertaken outside of the family home. “Much of Lucy’s mother’s support was supposed to have been provided by staff at the supported accommodation where she had a tenancy. However, due to covid there was no hands-on support or direct contact.” It has since been revealed that Lucy and her mother were not spending much time at the accommodation and were staying with Lucy’s aunt instead – the police warned her mother numerous times for breaking covid rules. Before Lucy’s accident, her mum was expecting a baby and had started a new relationship, however, nothing was known about her new boyfriend or about the impact he would have on the family. 'A degree of neglect was apparent' In July 2020, an ambulance was called to Lucy’s aunt’s house after she fell out of a 20ft-high bedroom window. The report stated: “While a criminal investigation was not pursued, there is a view that a degree of neglect was apparent. “It was following the child’s discharge from hospital to her mother’s care, which was agreed at a complex strategy meeting chaired by a senior children’s social care manager, that serious concerns about mother’s care of Lucy, who required additional care due to her injuries, once more became apparent.” At the complex strategy meeting, not all of the background information was shared and Lucy’s mum’s care was deemed positive once again. This was not helped by the police and social worker being unable to attend. The decision to return Lucy to her mother's care when she was discharged was not challenged by any agency. However, according to the review, there was “good monitoring and information sharing” in the days after from the social worker and the health visitor which revealed that Lucy’s needs were not being met and she was at risk of neglect. Care proceedings were then started without delay. Key learnings from the review included the importance of considering a parent’s history and vulnerabilities, pre-birth assessments, involving fathers, the impacts of covid and recognising and working effectively with families where neglect is an issue. ‘We can never be complacent’ Measures have since been put in place to try to prevent a similar occurrence, which will be monitored by the South Tees Safeguarding Children Partnership (STSCP). Edwina Harrison, independent chair of the STSCP, said: “Staff in these agencies successfully provide help for hundreds of children and young people every day, and a huge amount of work went into trying to reach the best possible outcome in life for Lucy. “This report looks in great detail about what happened and why that work did not have the effect that was intended. Safeguarding is never straightforward and the report has highlighted a number of learning points for all agencies involved in this and similar cases. “It is important that these changes take place as a matter of urgency and that we can be confident that we have better care and support for vulnerable children and their families. We can never be complacent when it comes to helping those most in need. “I would also like to take this opportunity to appeal directly to those families who are in need or who know of anyone in that situation to seek the help and support that is available and so that we can help them to protect children from harm.” For a North East politics and regional affairs digest direct to your inbox, go here to sign up to the free Northern Agenda newsletter Read More