Injured baby 'failed by health professionals'

The serious case review, carried out by Cumbria Local Safeguarding Children Board (LSCB), found a number of opportunities were missed to spot the potential for domestic violence in the home of the child, known as child C.

The review details how child C’s teenage mother, who has since pleaded guilty to child neglect and is awaiting sentencing, had formed a relationship with a man she met over the internet.

The partner, who it emerged had a previous conviction for threatening a former girlfriend, has since been convicted of injuring child C, who was admitted to hospital in September 2009.
 
Among health professionals to be criticised were those involved in the Family Nurse Partnership (FNP), the government’s flagship national service for vulnerable young mothers that was supporting child C and her mother.

The SCR found health professionals were too quick to accept child C’s grandmother’s initial assessment of her daughter’s new partner as a "lovely" man.

But concerns raised later by the grandmother about his "controlling behaviour" failed to ring alarm bells.

The safeguarding board said a health visitor should have asked child C’s mother about these concerns in private, but chose to do so when the partner was in the house.

Health professionals should also have raised concerns with police. If they had they would have known about the partner’s history of domestic abuse.

The LSCB was concerned that despite being highlighted as a vulnerable teenager, health professionals involved in the FNP had not looked into her family history.

The board also found that the supervision and management of child C’s mother’s case "did not meet the weekly standard that the FNP programme requires".

The board added: "Supervision had not provided sufficient opportunity for reflection and critical thinking about the emerging evidence of indicators of risk in this case."

Among recommendations made is that all nurses in the FNP take into account relevant family history and that professionals, particularly midwives and health visitors, improve information sharing.

An NHS Cumbria spokesman, also speaking on behalf of Cumbria Partnership NHS Foundation Trust and University Hospitals of Morecambe NHS Foundation Trust, said: "All the recommendations in this review are being implemented in full.

"For example, systems for sharing information between health professionals are being strengthened through the creation of a revised protocol for local health visitors, midwives and family nurses."

Cumbria County Council’s children’s services department is also called on to review how it shares information and links up with health professionals in supporting pregnant teenagers.