​​Reviews into two Northamptonshire baby deaths find ‘unacceptable practice’ and a substandard police investigation

Another dark day for Northamptonshire’s children’s services as both families were known to social services before their babies died

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By Sarah Ward

Within the last few minutes, the Northamptonshire Safeguarding Partnership has published two Child Safeguarding Practice Reviews into the tragic deaths of a six-week old baby who died in October 2019 and the later death of a six-month old baby boy who died during the lockdown of April 2020.

Both reviews have highlighted poverty and parental alcohol consumption as features in both cases and instances of ‘unacceptable practice’ by social services and lack of robust investigation by Northamptonshire Police have been found. Also once again failings in communication between the county’s public agencies has been uncovered.

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Six-month old Nikita (referred to in the reports as child AZ)

What happened?

One month into the first lockdown at 10pm on April 15 last year, emergency services were called to a flat in Kingsthorpe, Northampton after the father rang 999 to say Nikita had stopped breathing. Despite attempts to resuscitate him he died.

When police visited the house the next day, both parents were heavily drunk and their two youngest children were immediately taken into police protection and have since been put into foster care.

The parents were arrested for neglect but charges were not brought against them. 

An inquest into Nikita’s death returned an open verdict after medical experts were unable to ascertain the cause of death.

Family history

The family of five, who were Russian speaking, are described in the report as living in ‘abject poverty’. Seven months before the tragedy, while the mother was heavily pregnant, they had been evicted for failing to pay the rent and after calling their support worker from a local park one evening in September 2019, they turned up homeless and destitute at Northampton General’s accident and emergency department. The two children who were both under four did not have anything on their feet.

The family found another place to live, but the review says it was clear they were in crisis before the baby was born.

The family had been known to social services for a number of years and both of their other children were assessed as ‘children in need’, meaning social services would become involved.

The eldest daughter who had severe development difficulties (she had a development age as young as 16 months when starting school at four and a half), was out of school for a period of six months before her younger sibling’s death because the local authority had not been able to secure her a special school placement.

The lockdown meant the father was once again out of work and the family did not have any check up visits from either health or social services.

A social worker involved with the family told the review:

​​“Two weeks before Child Az’s death the building industry had shut down completely [because of the Covid Pandemic] and if you were a family living week by week, it would not take long for life to become very difficult. This may have impacted on the family’s ability to cope and perhaps using alcohol was a coping mechanism.”

There had also been domestic abuse incidents, with police being called a number of times although charges were not brought against the father, who the report says had come to England in 2008. On one occasion he had also called police saying that his pregnant wife had been drinking for days. 

The review found that alcohol played a large part in the lives of the parents.

It said: “Whether alcohol misuse was a means for the parents to deal with the challenges they faced is a question raised in this review. However, it is apparent that the parents had a lack of awareness that something was seriously wrong with Child Az on the night he died, which was seemingly impaired by their consumption of alcohol.”

Failings of the authorities 

The report, which was carried out by independent reviewer Moira Murray found: 

• A “significant lack of involvement” by both health visitors and social workers after December 2019, particularly given the concerns around poverty, alcohol abuse and a mother caring for a new-born baby as well as two small children, one with special needs

• Social services failed to carry out a pre-birth assessment which, it says, should have been a priority: “If this had been undertaken, the past history of the family may have become known, resulting in appropriate agency intervention.”

•  A social worker relied on the father to interpret in Russian on behalf of the mother and children, when best practice would have been to bring in an independent interpreter

• The initial investigation by the police on the night of the baby boy’s death was “not robust” and failed to gather evidence, as officers failed to consider neglect as a cause of death 

• The suggestion by a social worker to take the children into care when the family became homeless (section 20 order) was “unacceptable professional” practice

• The eldest daughter’s primary school had made a complaint about the input from social services and the lack of response by the Early Health Care Team

• There were failures in information sharing among agencies involved with the family concerning the disguised compliance of the parents and the extent to which they misused alcohol

• Concerns were also raised around the “lack of professional curiosity” from the disabled children’s team in relation to the welfare of the family’s eldest child.

Recommendations include

• Partner agencies to be reminded that when a child and family assessment is undertaken, especially when a family is homeless, a holistic assessment has to be made of the family’s needs

• Where there is concern about a mother’s alcohol consumption during pregnancy, practitioners need to be aware of the impact on the unborn baby of the risk of foetal alcohol syndrome

• A shared understanding of the criteria for referral to the Disabled Children Team needs to be put into place throughout the Partnership. 

The review commended good practice by the primary school of the eldest daughter and also the response of the Northampton hospital and midwifery services when the family arrived there in need of help.

Response from the authorities

A spokesman for the county’s safeguarding partnership said: “Significant learning has arisen for several agencies in the aftermath of this case which will help to provide a better understanding of the challenges practitioners face in cases such as these.”

Northamptonshire Police Assistant Chief Constable Simon Blatchly, said the findings has led to some significant learning for the force.

“While child protection officers police-protected the children, the initial part of our investigation was “not robust”. However, a debrief by a senior officer carried out at the earliest opportunity afterwards - and cited as good practice in this review - did seek to identify the issues raised, specifically the lack of awareness of possible neglect, and as such appropriate training around officers managing child deaths was carried out.

“Huge strides have been taken to improve our officers’ overall understanding of vulnerability, as recognised both by our National Child Protection Report last March and the PEEL assessment published last month, reports both carried out by Her Majesty’s Inspectorate of Police, Fire and Rescue Services (HMICFRS).

“We strive relentlessly to improve the way we protect people across the communities we serve and aim to take away the learning when we have fallen occasionally short.” 

Director of Children’s Services Cathi Hadley, said:

“It is deeply saddening for everyone involved when we see young lives cut short, particularly where it could have been avoided. 

“The dangers of alcohol consumption around very young children are well known, and the risks increase drastically if parents fall asleep, whether in the same bed or not.  

“There is still work to be done in terms of making sure we, as a local authority working with partners, pick up on the early warning signs that were present in these cases.  

“Since Children’s Social Care was put into the hands of the Northamptonshire Children’s Trust, Ofsted findings show a continuing trend of improvement, and I am confident we are tightening the net and increasing the chances of those warning signs being picked-up and acted upon.” 

Cathi Hadley

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The six week old (referred to in the report as Child Ay)

What happened?

In October 2019 the parents came home from a heavy night of drinking and fell asleep with the baby in their bed. At 4.30am the baby was found lifeless due to having suffocated.

Both parents were later charged with neglect and sentenced earlier this year.

The family

Neglect of the couple’s two other children, who both had disabilities, had been flagged up by a health worker as well as their school which in 2017 reported that the children were unclean, with matted hair and smelt of urine.

An assessment by social services decided that the children did not need to come under their attention and were not ‘children in need’. The family lived in a two bedroom flat, with the two elder children sharing a single bed, while the mother slept in the other bedroom alongside a freezer and washing machine and the father slept in the living room.

After the baby’s death police found the home littered with bags of rubbish and judged that there were signs of poverty in the way the family was living.

The mother had learning difficulties and the father was little known to the school or other authorities, although one of the children alleged a bruise had been caused by him.

Findings of the review

• No evidence that consideration was given to the fact the older siblings had disabilities, and how the added pressure of a new baby may create additional risk. An Early Help Assessment would have been a useful starting point to understand how the arrival of a new baby within the family unit might have led to additional support needs

• No consideration of how the family would be living within the two-bedroom flat when the baby was born

•  Safe sleeping advice was given but no evidence that the mother’s learning difficulties were taken into account. No evidence of safer sleeping advice given to the father.

Recommendations include

• The safeguarding partnership ensures professionals have a stronger understanding of learning difficulties/disability and the difference between both of these terms

• The partnership ensures professionals review their neglect training so it is multi-agency and focused on consistency

• Public Health Northamptonshire launches a Safer Sleeping campaign.

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Children’s services in Northamptonshire

The reports published today come just two years after two other reviews following the murders of Dylan Tiffin-Brown, two, and Evelyn Rose Muggleton, one. Both were known to social services and killed by their father figure. Social services came under severe criticism in both cases and said reviewers said opportunities had been missed to help the young children.

Dylan and Evelyn were both murdered

The Northamptonshire children’s services, which was responsible for protecting all of these children, has been failing for several years, and has been under the control of a government appointed children’s commissioner (although there has not been a report from Andrew Christie since last summer).

The service, which was turned over to a new independent trust last November, has suffered from a failure of management and its poor reputation and working conditions has led to an over reliance on agency staff as it has not been able to recruit to the positions.

A recent Ofsted report said the service has made improvements but it still has a long way to go.

In a statement Julian Wooster, Chair of Northamptonshire children’s trust, said “These are incredibly upsetting cases, and we owe it to these children, to ensure the learnings from these reports are put into practice.

“Being a trust gives us the opportunity to concentrate solely on delivering services for children, young people and families, to focus on improving our practice and to ensure every child and young person is given the safest possible environment in which they can thrive.

“Recent Ofsted visits have found that our services are improving. But of course there is no room for any complacency. We are just at the start - we know that there are still areas to work on and we have an improvement plan in place to address this.

“What I can assure you, is that we will work relentlessly to continue to make improvements to our services so that they are true examples of best practice to ensure we achieve the best possible outcomes for children and young people in Northamptonshire.”

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Child protection under the spotlight once again following death of Arthur Labinjo-Hughes

The murder of six year old Arthur, who was killed in Solihull during lockdown by his father’s girlfriend Emma Tustin, has put the nation’s children’s protection services under the microscope once again. Social services and police were made aware of the mistreatment Arthur was suffering at the hands of his father and his girlfriend but nothing was done and after suffering appalling neglect and mistreatment he was brutally killed.

A report issued yesterday by Ofsted’s chief inspector Amanda Spielman said too many vulnerable children are being left at risk of harm for far too long and said that almost half of council children’s services require improvement or are inadequate. 

The services come under the remit of local councils which during the Conservative’s decade of austerity faced severe funding cuts, with some authorities, like Northamptonshire deciding to drastically reduce areas such as youth services and early prevention.

Read the BBC report about the Ofsted annual report