The SCR was launched into the case of the 17-month-old girl, known as Child Au, who was admitted to hospital with a broken arm by her parents in 2019.
Doctors discovered evidence of five other fractures, sustained over a period of time and the girl's parents and have since been jailed after being convicted of injuring their daughter.
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But the review found that earlier concerns raised by health workers, including weight loss, developmental delay and intimidating and controlling behaviour by the mother, had not been effectively dealt with.
Child Au’s case had been allocated to a social worker for a single assessment and referred to the early help team at the now defunct Northamptonshire County Council in 2018 but “the plan was not actioned”, according to the SCR by Northamptonshire Safeguarding Children Partnership.
The toddler’s ordeal included having her arms taped up with electrical wire, surrounded by “dirty nappies and mouldy jars of empty baby food lying around” and lying on a bare mattress in her cot. This was reported by a heating engineer who had visited the family’s home.
Despite being later subject to a child in need plan and regularly seen by health visitors, GPs, paediatricians and social workers, evidence of neglect and abuse was not dealt with and the child remained in the care of her parents.
“Her weight and development were closely monitored and charted,” details the SCR.
“Although the indications of severe neglect may have been recognised by those who had professional contact with her, such concerns were not acted upon in a timely manner,” it states.
Concerns are also raised around health workers’ confidence in reporting to the area’s multi-agency safeguarding hub (MASH).
“Several health visitors who saw Child Au on a regular basis believed that, if a MASH referral was made, it would not reach the threshold for intervention,” the SCR reveals.
It adds: “The need to make a safeguarding referral when it is evident that a young baby is failing to thrive, whose mother is intimidating, controlling and admits to having attachment issues with her child, should have been apparent to those health professionals involved with Child Au.”
The toddler is now in foster care and “is continuing to recover from her ordeal as a result of the skill of the clinicians who treated her and the love and care she is receiving from her foster carers”, says the SCR.
“Child Au will however require specialist intervention to ensure that she reaches her full potential, which is the legacy of the neglect she suffered in the first 17 months of her life.”
Among recommendations made is for social workers to “have the confidence to challenge parents where the welfare of a child is of concern” and to effectively assess the mental health of mothers.
Meanwhile, a safeguarding board review is to be launched into the death of five-year old Logan Mwangi in Bridgend, who was murdered by his mother, stepfather and teenager last year.
The review by Cwm Taf Morgannwg Safeguarding Board is expected to be completed by autumn this year.
