A Wearside baby that died and three others that were injured were 'let down' by children's services experts and other professionals, a series of critical reports published today have said.
Sunderland Safeguarding Children Board (SSCB) apologised "unreservedly" and said the death of the child - referred to as Baby E - and injuries to others, known as Baby O and Baby W, were something they "deeply and profoundly regret."
The findings of three serious case reviews made public today said the infants and their families could have received better support from various organisations, including social workers, police and the NHS.
The babies at the centre of the reports came from four separate families. All were under the age of one. The four cases happened between 2011 and 2015. Last summer saw an Ofsted report find safeguarding services in Sunderland to be inadequate, although a monitoring report last week said progress was being made by the services.
In the case of Baby W, a sibling identified as Baby Z was also part of the review.
A fourth serious case review into injuries sustained by an infant referred to as Baby G is yet to be published as the matter is still the subject of an ongoing investigation.
Adult family members in the cases of Babies W, E and O were found guilty of related criminal offences. In the case of Baby E, the cause of her death was unascertained, although a coroner found no-one to be responsible for the death.
Babies W, G and O all now live in different extended or new families.
To coincide with the publication of the serious case reviews, SSCB commissioned Dr Mark Peel and Dr Trish Shorrock to compile and independent report looking at issues that emerged from the incidents.
Although they found the serious case reviews did not evidence 'endemic or systemic failure' there were still many underlying issues, such as poor communication and various agencies not working well together, 'inconsistent, limited' management, a workforce under pressure with high workloads, too few staff and limited resources highlighted and a 'rapid turnover and poor retention of staff' also noted.
Jane Held, Independent Chair of Sunderland Safeguarding Children Board, said: "Sadly, these babies and their families were not always served well by the professionals and agencies responsible for supporting them. These included the NHS, early years services, education services, the police and children’s social care.
"We let these babies and their families down. This is something we deeply and profoundly regret and we apologise unreservedly to all those involved.
"It is however important to acknowledge that responsibility for the injuries to three of the babies rests with those the court found culpable. Although the cause of death for Baby E was unascertained, the Coroner was clear that no-one was responsible for her death. Also that there is no direct causal link between the poor practice in these cases and what happened to all of these babies in their everyday family life.
"The standard of practice in these cases and more widely in 2013 was not up to the standards we would expect. A significant amount of work has been done since July 2015 to improve safeguarding across the partnership.
"This has resulted in a steady improvement over the last year. Plans are progressing to ensure that all the agencies involved provide the services that children, young people and their families need to live safe, happy and healthy lives.
"These include safeguarding partners working closely with Sunderland's Commissioner for Children's Services and a radical rethink by the City Council of the way it delivers services for children which will see it setting up an independent company to deliver these on its behalf.
"Although there are still many improvements to make I am pleased to see that Ofsted have noted progress is being made in their first monitoring visit to Sunderland since the inspection and that services appear to be heading in the right direction."
Baby E died in September 2013, aged four months.
The serious case review said: "The family had been known to agencies for several years Professional concerns included parental substance misuse, poor school attendance and the behaviour of the two eldest children, but these concerns had never culminated in the children being subject to Child Protection of Child in Need Plans, although 'child in need' services had been offered to the family."
At an inquest into the death of Baby E, a coroner said the primary cause of death was the child sleeping in her parents bed but concluded there was no evidence drugs caused or contributed to the death. Baby E's parents were convicted of child cruelty and received a six month prison sentence suspended for two years.
Baby O was taken to hospital in August 2013, at the age of six months, after she was discovered to have a fractured left leg and bruising to her face, lower back and legs.
A review said she had been living in "poor home conditions" before being removed to the care of her grandmother, who struggled to look after her and three other siblings.
After her injuries were detected, Baby O and her sister were moved to foster carers.
The report added: "The basic care provided to the children by paternal grandmother was good but it is clear - as grandmother indicated to some professionals - that she struggled to cope with looking after four children under four years.
"If more effective, accurate background checks had been completed, the children may not have been placed with her."
The grandmother was convicted of child cruelty/neglect in June 2015.
Baby W was admitted to hospital in November 2012 at the age of 11 weeks and was found to have a fractured skull. Both he and his three-year-old brother - referred to as Child Z - were then placed in foster care and were adopted in 2014.
SERIOUS CASE REVIEW: BABY O
Six-month-old Baby O was taken to hospital in August 2013 and it was discovered she had a “non-accidental” fracture to her left leg and bruising to her face, lower back and legs.
A review said she had been living in “poor home conditions” before being removed to the care of her grandmother, who struggled to look after her and three other siblings.
After her injuries were detected, Baby O and her sister were moved to foster carers.
The report added: “The basic care provided to the children by paternal grandmother was good but it is clear - as grandmother indicated to some professionals - that she struggled to cope with looking after four children under four years.
“If more effective, accurate background checks had been completed, the children may not have been placed with her.”
The grandmother, who struggled as she looked after two other young grandchildren, was convicted of child cruelty/neglect in June 2015.
Many of the infants appointments were missed and on one occasion, the two children were left home alone and later put into the care of their dad’s mother.
Midwives and health visitors reported struggles in seeing mother and baby and the eldest child’s school had raised concerns both parents had been taking her to school, but did not have Baby O with them.
When a check was made with the help of police, the baby was found alone in the house, strapped into a buggy, leading to the arrest and caution of the parents.
In September 2013, the mother was admitted to hospital with multiple serious injuries after it was claimed by her partner she had fallen down the stairs - he denied any violence.
She failed to recover, or take up medical advice or treatments, and died in 2014.
SERIOUS CASE REVIEW: BABY W and CHILD Z
Baby W was admitted to hospital in November 2012 at the age of 11 weeks and was found to have a fractured skull.
Both he and his three-year-old brother - referred to as Child Z - were then placed in foster care and were adopted in 2014.
The review into their care showed the baby’s injury was not deemed to be an accident and that should have led children’s services to notify the board that a serious care incident had happened so a decision could be made over a review.
Questions were raided when the chairman of the adoption panel looked at the family’s circumstances, sparking the serious case review in 2015.
During the review, the mother, named as Marie, and her grandmother disagreed with concerns about the mother’s lifestyle - drinking, taking drugs and not properly caring for Child Z - and said information put to court proceedings were wrong and untrue.
The injury happened to the baby in her new home and the mother, who first became a mum at 17, said this was caused by a friend, but could not give any further details.
The report states: “Neither Marie nor her grandparents were able to say what services might have helped,” adding they were distressed about the decisions made about the children.
Findings in the review included a lack of “robust assessment and decision making,” a limitation in the view of professionals, which prevent them from seeing Marie as “neglectful,” and missed chances to share concerns between agencies, with that picked up by the Ofsted report in July 2015.
SERIOUS CASE REVIEW: BABY E
Although the cause of death for Baby E at the age of four-months-old was unascertained, the coroner was clear that no-one was responsible for her death.
The parents of the infant, who was born in May 2013 and died in the September, could not be reached to take part in the report, but the grandmother on the mother’s side helped.
The authors found the grandparents were found to be committed to helping their daughter and described the family of three other children, fathered by another man with depression and other mental health issues, to be lively and a “happy, loving family” with “hugging and lots of fighting.”
The report into “The standard of practice in these cases and more widely in 2013 was not up to the standards we would expect.
“A significant amount of work has been done since July 2015 to improve safeguarding across the partnership.”
The report concluded: “It is impossible to state whether the sad death of Baby E was preventable.
“The family were advised by the health visitor about the risks of co-sleeping but the parents elected, as many do, to place the baby in their bed to sleep.
“The cause of death was unascertained meaning it was not possible to find an explanation as to why the baby died.
“However, the circumstances in which the baby was found after her death gave cause for concern and some difficult questions had to be asked of the professionals who knew the family.
“Just as it was not possible to predict the death of Baby E, neither is it possible to attribute the cause of death to any failings on the part of professionals who knew the family.
“The review has however highlighted the need for professionals to be persistent, curious and above all child-centred when pursuing concerns about the welfare of children.”