Southampton Safeguarding Children Board, 2014

This is the serious case review report in respect of two children known in this review as Child I and Child M. Child M died aged 2½ in January 2011 and along with his sibling was subject of a child protection plan at the time of his death. Child M’s half-brother, Child I, died three months later in April 2011 at the age of 4½. He was understood to live with Maternal Grandmother but was in the sole care of Mother at Maternal Grandmother’s house at the time of his death.

Recommendations are providing to address the following issues :


- No pre birth assessments were carried out and there was therefore a lost opportunity to analyse all the information known across the professional network and consider Mother’s capacity to parent.
- Work with the family as a whole and particularly Mother as a learning disabled parent with complex needs, failed to keep a focus on risk to the children at the same time as providing services to meet the adult’s needs.
- Although there were concerns in a number of organisations about the failure to adequately address risks to the children, the escalation processes were not used to bring these concerns to the attention of senior managers in children's social care.
- Strategy meetings were not used in line with procedures
- The post of Designated Doctor for child deaths is relatively new within Southampton and in addition, there are indications that some aspects the rapid response procedures cannot be consistently implemented.
- The child protection conference system did not work well in gathering all relevant information, analysing the level of risk and ensuring that effective plans were implemented.
- Supervision was either absent or ineffective in supporting an analysis of risk.
- The support available to the child minder in escalating concerns was not effective.
- There was a lack of clarity regarding the role of emergency duty team or hospital social workers in “agreeing discharge” and there was insufficient consideration given to the implications of discharging a child on a child protection plan from hospital outside normal working hours.
- There was a misunderstanding regarding the legal status of Child I due to the failure to finalise the draft Residence Order and lack of information before the court regarding the involvement of children's social care. This led to an inappropriate reliance on Maternal Grandmother to exercise Parental Responsibility and keep Child I safe.