That is the conclusion of a serious case review on the child, known only as Baby T, who was admitted to St Mary's Hospital in the summer of 2012 with severe trauma injuries. The clinical opinion was, according to the report, that the injuries were likely to have been caused by being shaken by an adult.
Criminal neglect charges weren't pursued to trial because medical evidence couldn't identify the time when Baby T received his injuries. However, a serious case review was commissioned in August 2012 and was completed eight months later, although it has only just been published. The report was compiled by independent reviewer Barry Raynes and approved by the Local Safeguarding Children Board (LSCB).
Among the findings, the report said that there had been an over-reliance on less qualified staff in the Isle of Wight Council's Children's Services, a failure to collate and analyse information and a failure to record actions. It said that the Children's Centre, which is central to the review, has been subject to a 27% cut in its budget from the Isle of Wight Council, yet during the same period the number of children on protection plans had risen. The serious case review echoed a number of findings from the Ofsted inspection of Children's Services, which found them inadequate.
In conclusion, the report found that a restructuring of Children's Services in January 2011 - the third in four years - was hurried, ill-thought through and responsible for some of the difficulties identified in the review.
The report said that the father told mental health workers that he fantasised about hurting small animals and people and had been denied contact with another of his children. The mother had said he had abused her many times and also had a troubled history. The reported added that there had been considerable contact between professionals and the mother, and concludes:
It is difficult to believe, had professionals been aware of all this information, that they would not have considered baby T or S to be at risk from significant harm. There has been eight contacts between family members and professionals with the First Response Unit and there was considerable background information available to health and Children's Services staff.....Had professionals assessed the dangers correctly and taken appropriate action in ensuring that baby T was not left in the care of father (S) then the harm that has befallen him would have been prevented.
A total of 14 recommendations were given to the Isle of Wight Council, including better training of staff and recording of their work.
A second serious case review was also published on Tuesday, the full details of which have been withheld over fears for the welfare of children involved, which also criticises Children's Social Care on the Isle of Wight. Findings in the second report echoed many of Ofsted's conclusions of an inadequate service, and included concerns that the full range of risks to the extended family, and from the history, were either not considered or given enough credence. It added there was a very serious failure by managers in Children's Social Care to review and account for decisions in the First Response Unit. And, in conclusion, the report said there were opportunities for early intervention by Children's Social Care, but requests by other agencies were not acted upon until very late. The Serious Case Review recognised there was good practice on the part of agencies including mental health, midwifery safeguarding advice, the health visiting and the Children's Centres. The report adds that if there had been an early intervention, the outcome may have been different.
A number of recommendations have been published for a number of agencies, including the IW Council, NHS Trust and schools.
The newly appointed Chair of the Isle of Wight Safeguarding Children Board, Maggie Blyth, commented:
Whenever a child has been the victim of harm it is deeply distressing and a cause of great sadness. It is vital therefore that the events leading to such situations and the actions of the professionals involved are thoroughly scrutinised. Protecting vulnerable children is the responsibility of many agencies and the reports of their involvement in these two cases have been considered by the independent review panels which have examined how they responded in each case and identified whether more could have been done to protect the children involved.
In January 2013 an Ofsted inspection found child protection arrangements on the Isle of Wight to be failing and judged them 'inadequate'. The two reviews published today relate to incidents that occurred before the inspection so it is therefore not surprising that the review findings mirror those of Ofsted. In January 2013 the government issued Children’s Services with an improvement direction. It is acknowledged that since January 2013 however, a great deal of work has taken place to strengthen children’s social care on the Island, including the implementation of a range of measures to improve front line services. It is self-evident however, that there are no quick fixes to these problems and time will be needed to ensure sustained improvement. I am sure that the messages from these reviews will contribute to that improvement. We owe that much to the children concerned. The Isle of Wight Safeguarding Children Board will be working closely with all partner agencies to ensure the recommendations from these two serious case reviews are taken forward without delay.