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.