Social workers failed to act to protect a vulnerable toddler less than three weeks before she was hospitalized with a broken arm, despite warnings that she was neglected and at risk of harm, an inquiry report has concluded.
A review found health visitors and social workers repeatedly delayed intervening over months of mounting evidence that the girl was experiencing physical and emotional trauma and her parents were disastrously failing to care for her.
The girl was chronically underweight, left for hours in dirty nappies, slept in a bare cot in midwinter, was socially isolated and never spent time with other children, had no toys, and presented as “sad, watchful and frozen”, the report says .
“The home environment in which [the child] spent the first 17 months of her life can be described as one of chronic neglect, fear, understimulation, discomfort, loneliness and physical harm,” the child safeguarding practice review found.
Northamptonshire Safeguarding Children Partnership, which carried out the inquiry, said professionals had failed to act decisively on the reams of evidence they had accumulated, leaving the girl exposed to months of significant harm and neglect.
“If there is one important and resounding lesson to be learned from this review is that it is not enough for professionals to observe and record signs of neglect and abuse. Action is required if children are to be protected from significant harm,” it concluded.
Health visitors had been concerned about the girl’s growth and development soon after her birth. Although they noted the mother had mental health problems, lacked attachment to her daughter, and could be hostile and evasive, they failed to refer the case to child protection teams for more than a year.
When social workers finally got involved in September 2018, there were further delays and drift, and the situation came to a head shortly before Christmas that year when an engineer sent to repair a boiler raised the alarm after seeing the girl in a cot with her arms taped to her sides with electrical wire and surrounded by used nappies.
Social workers visited the family again but despite clear signs things were not well they failed to ask about the taping of the girl’s arms. They decided not to escalate the case, instead leaving her parents with instructions “on what was needed to change” in their parenting methods to ensure the child’s safety over the holiday period.
Reflecting on the decision not to intervene, the inquiry report says: “In light of the stark evidence of neglect, the lack of immediate action by children’s social care to initiate child protection procedures raises serious questions of professional judgment.”
In January 2019, the child was admitted to hospital in agony, three days after her parents reported to social workers the girl had a swollen arm. X-rays revealed a broken arm, as well as multiple historical fractures in her legs. She was immediately taken into police protection and her parents arrested.
Social workers had not lacked awareness of the potential risks to the girl, the inquiry found. There was, however, a lack of “management oversight”, which, coupled with frequent change of social workers over the three months of their involvement, resulted in the girl experiencing significant harm.
Asked by the inquiry why they had not referred the girl to child protection earlier, the health visitors said based on previous experience they believed child protection intervention thresholds were set so high their referral would inevitably be rejected.
The girl remains in care and, according to the Northamptonshire Safeguarding Children Partnership, “beginning to thrive with her foster carers”. Her parents, Sarah Elizabeth Cunnington and Ryan Eames, were each jailed for two years and seven months in October 2021.