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Bonkers Blog March 2014

Index: 20092010201120122013201420152016201720182019

5 March (Part 2) - Another Bexley management failure results in death

How many Rhys Lawries does Bexley need? This time a child died of rickets, an easily preventable disease. The serious case study made these comments and references… 

• A lack of ownership and accountability in practice.
• Newly qualified and/or inexperienced practitioners with poor senior management oversight of the case.
• Poor quality of assessments, influenced by a lack of depth and rigour of analysis and interpretation.
• Poor ongoing assessment of risk with little evidence of considering the totality of events and behaviours.
• Poor compliance and in some cases lack of knowledge of policies and procedures.
• Poor inter and intra agency communication, including inconsistent and at times lack of documentation.
• Limited evidence of the voice of the child in professional decision making.
• An apparent lack of evidence of awareness/knowledge of the impact of maternal nutritional status on the health of either the unborn or new born infant.
• The quality of assessments was poor with little recognition or analysis of risk and therefore decision-making was flawed.
• Professional practice focussed on maternal/parental needs over the needs of the child. There was no evidence of challenge of the parents’ views/representations or of their contradictory behaviours with a resulting loss of focus on the child.
• The ethnicity, diversity and possibly professional status of the family distracted professionals from challenging them. Supporting the equality and diversity rights of the family appeared to take precedence over the voice of the child.
• There was a lack of ownership and accountability by professionals, delegation to junior staff or other professionals was evident and there was no follow up or review of concerns. This contributed to the lack of identification of risk and increasing vulnerability was not picked up.
• There was a lack of senior management oversight, this includes directly to support junior staff and organisationally. Roles were often confused and not understood. The quality assurance function of management oversight was missing and led to continued poor assessment and decisions.
• The role and function of named nurse in acute trust 1 was not utilised as set out in Working Together and led to confusion for other agencies.
• Policies/procedures and guidance were not complied with in particular Discharge planning, DNA management, Core Assessment, rapid response meetings, managing allegations, the LADO role and nutritional guidance. This contributed to the lack of effective risk assessment and planning.
• There was poor Inter and Intra professional communication, leading to gaps in knowledge, misleading risk assessment and awareness of vulnerability.
• The lack of understanding of the impact of maternal nutrition/health on the unborn infant/baby resulted in no identification of risk or management plan.
• There was a consistent lack of professional curiosity and challenge to both parents and other professionals, this contributed to poor assessment, lack of recognition of risk/vulnerability and subsequently poor ineffective management.
• The role of Named senior officers within agencies and the LADO role and process was not used and does not appear to be understood.
• There are familiar learning points identified within this case to a previous local SCR in 2009 which suggest that previous learning has not been embedded into practice.
• The repeated lack of recognition of risk was not recognised as there was no professional who considered the whole picture or challenged previous decisions or lack of them. This lack of identification of increasing vulnerability also appears to have conversely provided reassurance and served to reduce the risk observed by professionals as care unfolded.

The News Shopper reports that Bexley council says “lessons have been learned”. That’s alright then. The News Shopper also reports today that Bexley’s Head of Professional Standards and Quality Assurance has been awarded an MBE for services to children and families. She has been in post only since last August but says the award was for “social workers and managers”.

Note: LADO - Local Authority Designated Officer. SCR - Serious Case Review.


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