Is sorry now just an empty word in Northamptonshire?
Is sorry now just an empty word in Northamptonshire?
Following a report into how terrible failings led to another Northamptonshire baby suffering severe harm, we ask have we now heard too many apologies?
By Sarah Ward and Natalie Bloomer
A Northamptonshire baby was so badly neglected that she had learned to silently cry. Described as a ‘frozen’ child, sad and with a blank expression, when she reached her first birthday she still fitted into three month old clothing and was severely underweight.
Throughout 2018 she was being horrifically abused and neglected by her parents Sarah Cunningham and Ryan Eames- who were given to two year prison sentences last year.
A heating engineer who turned up to do a job at the family home found the baby lying in a cold bare cot, surrounded by mouldy baby food jars and with her hands taped together with wire.
His actions helped the baby to be safeguarded and removed from the family home, but health visitors and social workers already knew enough about the child’s circumstances to have taken action themselves, having sat in the home on a number of occasions and seen how Cunningham in particular neglected her young daughter.
Yesterday, at a press conference arranged alongside the publication of an independent report commissioned by the Northamptonshire Child Safeguarding Partnership, many of the senior staff in the public services that had failed the young baby apologised. But is sorry enough? And have we heard it too many times in relation to these services?
NN Journal asked all of those on the press conference panel whether they were ashamed, but no one admitted to shame. Instead they said they were sorry. Countless times.
In Northamptonshire we have been here before. Six months ago two independent reports were released after the deaths of two Northamptonshire babies, who were less than a year old. The reports made clear they had been failed by the authorities in Northamptonshire which were supposed to protect them.
Less than two years ago there were also reports following the deaths of two young children, Dylan Tiffin Brown and Evelyn Rose Muggleton, who were killed at the hands of their father figure. Again there were serious professional errors. Apologies were made and promises that lessons would be learned.
A child failed by all
Child Au (as she is anonymously referred to in the report) was born in a neighbouring county in August 2017 and lived in a homeless hostel with her mother Sarah Cunnigham and father Ryan Eames. Almost immediately health visitors raised concerns noting that the family’s room was ‘cluttered with rubbish’ and that Eames was doing a lot of the care of the baby as Cunnigham believed the child preferred him.
The following month, the family moved to Northamptonshire to live with Cunnigham’s parents. During a telephone conversation with their previous health visitor the mother said she had seen blood in Child Au’s mouth and was advised to take her to the GP.
The first time a Northamptonshire health visitor saw Child Au she was around a month-old and again concerns were raised. A referral was made to NORPIP (a charity to help parents form attachment to their babies) however they did not attend.
This would be the first of many interactions between the family and Northamptonshire’s health visiting team. In the first 17 months of Child Au’s life, health visitors repeatedly raised concerns about her low weight, developmental delays and attachment issues with her mother. However, it wasn’t until September 2018 around a year after their first visit to the family that the team made a referral to MASH (the multi-agency safeguarding hub).
On one occasion during that time it was noted that Cunningham ‘hated it when the baby cried, couldn’t cope and would often leave her to cry in her cot alone’. This was witnessed by the health visitor and community nurse during a visit to the family home in October 2017 when the baby could be heard crying from upstairs and Cunningham refused to go and get her saying that she cries herself to sleep.
“It can be surmised that Child Au learned that there was little if any point in crying, as illustrated by her not indicating any discomfort when her nappy was dirty and her parents admitting that they found her awake during the night, lying silently in her cot. Health professionals noted that she presented as sad, watchful, and frozen,” the safeguarding review said.
In January 2018 Cunnigham turned up with a black eye at a health clinic she attended with Child Au. A week later the GP raised concerns about the child with the community nursery nurse which were passed on to the health visitor. However it was another seven weeks before the family were seen again when Child Au was noted to be quiet, with no response to being put back in her cot whilst wide awake.
Shortly after, the health visiting team agreed for a Graded Care Profile to be completed which can be used to assess neglect. It was also agreed that a review as to whether a referral to MASH (the multi agency safeguarding hub) should be carried out.
In July a health visitor noted:
“[Child Au] is chronically socially isolated, parents consistently unable to provide positive and enough parenting that is safe; Child Au is grossly under-stimulated and is subject to neglect.”
There was still no referral to MASH.
By the time Child Au was a year old her development was months behind what it should have been and her weight was on the ninth centile on growth charts. In September when her weight dropped again, her GP referred her to a paediatrician who said there were clear concerns about neglect. It was only then that the health visiting team made a referral to MASH.
The first time a social worker visited Child Au she was 13 months-old and was wearing a top suitable for a three month-old. It was another month (October) before she was seen by a social worker again and not until December that their assessment was completed. However, due to how long the assessment had taken and because the social worker had left the department by then, the team manager decided that another should take place.
Just before Christmas, a contractor for a housing provider visiting the family’s home to carry out some work reported that Child Au was in her cot, with her arms taped up with electrical wire and that there were dirty nappies and mouldy jars of empty baby food lying around. A housing tenancy support officer went out to the house the same day and found the child with her arms ‘taped up’ and in a cot without any sheets or bedding.
The third social worker to be assigned to the family was contacted by the housing provider but it was another day before they visited them and the first time in three months that Child Au had been seen by a social worker. A decision was made that the parents needed support and despite repeated concerns by the housing provider the child was left in the care of her parents over Christmas.
In January on the advice of the social worker, Child Au’s parents took the 17 month-old to A&E with a swollen arm which was found to be fractured and needed surgery. She was also found to have bruising to her eye area, lower back spot/bruising and nappy rash. Her weight was 1st 2lbs - just a pound heavier than she had been at 8 months-old. A skeletal survey revealed five further fractures all at different stages of healing. The review said:
“Given that the five fractures were found to be at different stages of healing, the question has to be asked as to whether the reason Child Au was not pulling herself up, standing or walking was because she had suffered two broken legs.”
Finally on January 10th 2018 Child Au was taken into police custody and later placed in foster care. The foster mother noted that Child Au had learned to shed silent tears.
Inadequate service
Northamptonshire’s children’s services were rated as inadequate by Ofsted in 2018 after it found hundreds of children in need of help had not been assigned a social worker.
A children’s commissioner was sent in to turn the service around and in November 2020 the services were taken out of the hands of the Conservative run authority and handed over to an independent children’s trust.
The local politician responsible for children’s services
Cllr Fiona Baker became the local councillor responsible for children’s services across Northamptonshire in January 2019 (at the then county council) and she has continued the role at the West Northants unitary council.
We asked her yesterday whether it was time for her to go and if not now, whether she would if her promised improvements did not materialise at the next Ofsted inspection (thought likely in the autumn).
She said:
“That’s not up to me to decide. I think the work that I do within our service is rated good by my colleagues in the council. They see me doing a good job. So I dont know so perhaps I should stand down if that happens (a failure to secure an improved Ofsted inspection). But I’m not an operational person I’m an overview person.”
Asked why the neglected child was not taken from her parents sooner she said:
“I admit that it was a failure on our part that we did not intervene and take that child away, But it is a very fine line that we go through because we have a reputation in social care that we take children away and we don’t want that. We want to help parents where we can and in this case we may have been able to help with mental health help for the mother, we may not, we don’t know because we did not put that in place.”
Perhaps not recognising the absurdity of her words she ‘thanked god’ that the heating engineer had visited the home when he did.
The children’s trust
As NN Journal has reported before, the children’s trust had not produced a public report into its operations. Yesterday chairman Julian Wooster said there would be one out this summer.
There has been a long term issue with a shortage of social workers in Northants and a reliance on agency staff.
Yesterday Wooster told us the vacancy rate is currently around ten percent and that Northamptonshire was faring better than many other children’s services.
“We are managing that and reviewing whether we need those posts filled and whether we need more early help services, which is what this family should have received from the beginning.”
He said the culture of the service had moved away from the previous one of blame and the morale of staff was higher than under the former control of the county council.
Northamptonshire Healthcare Foundation Trust (NHFT)
The health visitor service is run by NHFT. Yesterday asked whether Northamptonshire residents should have faith in the service in light of the severe failings and lack of action to help a neglected and abused child chief operating officer Jean Knight, said:
“It is very shocking and I don’t think anyone who reads the report will think anything else. For us it is about how people learn from that and I hope people do have faith because our health visitors see a number of children and families and everyday they offer significant support.
“I don’t think anybody would say that we acted quickly enough because we didn’t. There should have been more robust challenge of the parents.”
She said NHFT would now focus on the learning and that now health visitors had the opportunity to discuss more complex cases with senior staff.
The recommendations
The review has made seven recommendations to the Northamptonshire Safeguarding Children Partnership (NSCP). They are:
The NSCP seeks assurance that all partner agencies recognise and act where children are experiencing neglect
The NSCP should consider how frontline practitioners can be enabled to work with families who challenge professional decision making and actions, whilst maintaining a focus on the needs of the child.
Practitioners should be reminded of the importance of the need to assess a mother’s mental health during pregnancy and after a baby is born
Northamptonshire CCG to require a protocol is produced between acute and community trusts to ensure that appropriate decisions and responses are made when a child’s presentation for a medical condition could indicate neglect and abuse
The NSCP should seek assurance that work undertaken concerning the criteria for convening Strategy Meetings is effective.
The NSCP should seek assurance that paediatricians take account of the weight given to the words used and opinions expressed in assessment reports concerning children, and the impact this can have on any future interventions/outcomes for the child.
The review’s report should be required reading for all professionals working with children in Northamptonshire to remind them that it is not enough to observe and record indications of neglect and abuse. Action is required if children are to be protected from significant harm.
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More excellent and incisive NNJ reporting. It's a complete disgrace, but, there seems to be no way any elected representatives or public servants take responsibility for anything these days. Your investigation of our MPs the other day was a prime example of this. Keep up the brilliant work. I tell everyone I meet these days to subscribe and support your efforts and I share your work all the time.
When services are starved of funding through 10 years of austerity and local politicians boast of holding council taxes at low levels, there are consequences.