Report reveals how premature twins were allowed home to mother with history of neglect

The injuries, which were picked up by a hospital scan in late 2017, led to the infants – known as Child B and Child C – being removed from the household by children’s services in Kirklees.

Yet the babies had already been placed on a protection plan BEFORE they were born five weeks prematurely.

However gaps in information coupled with incomplete assessment meant that health staff failed to understand the “pernicious nature” of neglect in the family and the “improbable” prospect of long-term good quality care.

Two older children at risk of neglect had been made subject to child protection plans in 2016.

The incident occurred whilst children’s services in Kirklees were being run by a government trouble-shooter sent in by the Department for Education (DfE) after a damning Ofsted report rated the council’s children’s services as “inadequate”.

In the months leading up to the council’s intervention health professionals worked with the mother, who had learning difficulties, and with the father, who was known to be volatile.

The mother, said to be “extremely vulnerable in her own right”, also expressed “hostility and resistance” towards accepting advice or support and “did not engage well” with professionals working with her about the concern for her children.

There were also concerns that two older children, born to different fathers, were already suffering from neglect and despite the introduction of child protection plans in October 2016 their home conditions were “not improved”.

The family was “well known” to services in Kirklees.

A report said “clear assessment activity, persistent curiosity by all professionals and creative information sharing” was “essential” but was “lacking”.

A Serious Case Review released via Kirklees Safeguarding Children Partnership (KSCP) on October 9 revealed that a pre-birth assessment in September 2017 was begun but not completed.

In addition multi-agency partners working with the family did not receive any interim findings.

A Child Protection Review meeting held in October 2017, a month prior to the twins’ birth, concluded there had been “lots of improvements” but there was no evidence that the mother had changed her parenting style.

Instead improvements had been made by her sister and a friend.

At that same meeting the unborn twins were placed on a child protection plan because of risk of neglect.

A week later the decision was made that the twins could be returned to their mother’s care following their hospital birth. A pre-birth assessment was left incomplete and there is no evidence that a full discussion with multi-agency colleagues took place.

The report says: “In the two weeks prior to the premature birth, home conditions deteriorated leading to an emergency core group being held on November 27.

“There are no minutes of this meeting however the original decision to return the children post-birth to [the mother’s] care was implemented, suggesting that multi-agency contingency planning was weak.”

At the time of the twins’ six-week developmental assessment a doctor raised concerns about one child’s poor weight gain. There were no symptoms of fractures or bruising on either of the babies.

However two days later the mother took one of the twins to hospital in the early hours, concerned about bruising on her face.

A scan revealed the existence of fractures and consequently the second twin baby was examined, and evidence was found of multiple fractures also.

Both children and their older siblings were subsequently all taken into the care of a local authority.

The Serious Case Review says the appalling incident in 2017 came at a time when social care of children in the borough was under “significant scrutiny”.

Following a report in 2016 from the education watchdog Ofsted, which said council-run services for vulnerable children in Kirklees were “inadequate”, the government appointed children’s commissioner Eleanor Brazil to oversee an improvement plan.

Leeds City Council’s child services chief Steve Walker was later brought on board to lead the recovery.

The KSCP said the case review into the babies’ treatment was “based on a premise of not seeking to attach blame to any individual professional or agency for the injuries which were inflicted”.

Instead it was actioned “to understand the rationale, impact and context of the agencies’ response to the family of these children”.

Sheila Lock, independent chair of the Kirklees Safeguarding Children Partnership, said the review was commissioned after the twin babies suffered injuries whilst in the care of their parents to look into the support provided and examine agency involvement in relation to the two older children.

She said: “The purpose of the review was to understand agency involvement with this family and to identify further work that could be done to strengthen professional practice in the wider children’s system.

“The review recognises that, at the time the injuries occurred, local safeguarding practices had been assessed by Ofsted as inadequate. At the same time, and very importantly, it is also clear that a great deal of work has taken place in the intervening period and that this is bringing ‘rapid, significant and sustained improvement’.

“Safeguarding arrangements in Kirklees were re-inspected in 2019 and are no longer the subject of intervention. Our work to support and safeguard children has developed tremendously, including the way in which neglect within families is identified, assessed and handled.

“We can confirm that steps have already been taken to implement all of the learning from this Serious Case Review. However, as a partnership, it remains our absolute priority to continue improving and to achieve the highest possible standards in keeping children and young people safe from harm.”

Tony Earnshaw , Local Democracy Reporting Service