The death of ‘Polly’ from Derbyshire, a 21-month-old, resulting from her being ‘stamped on’ by her mother, leaves a horrible feeling of ‘here we go again’.
As with so many serious case reviews, opportunities were missed. There was poor communication between professionals and the focus of activity seems to have been on the mother. There was concern before Polly’s birth resulting from her mother’s substance abuse, emotional volatility and violent outbursts. That concern continued following her birth and at one point, as a result of domestic violence, Polly was subject to legal proceedings and placed in foster care. But children’s services professionals were reassured by what appeared to be a loving relationship between the mother and Polly.
From time to time, Polly was taken to hospital with a number of injuries. This was explained as part of the risks or health issues that any young child might experience.
One of the biggest issues raised is the lack of curiosity on the part of professionals. This resulted in an inadequate exploration of the detail of the origins of the injuries or health conditions or the lack of questioning about the actual care (or lack of it).
Lack of curiosity is often a core issue in serious case reviews. But its familiarity does not seem to drive more robust questioning, exploration and engagement. It could of course be that these cases are so exceptional and the fallibility of human judgement and decision- making means that mistakes will occur from time to time. That does not feel a comfortable position to take.
At the same time, professionals have to engage reluctant and maybe oppositional and aggressive parents. They will be drawn to ‘normalising’ injury or events. They are faced with having to reach a high bar when it comes to the courts. The question is how to remain curious and ask questions that do not result in the breakdown of the relationship with parents. That also means sharing concerns, doubts or anxieties with colleagues.
None of this is easy for professionals under pressure with high workloads and endless to-do lists. But without this, there will be more children like Polly, where we are left sick by reading about the stream of missed opportunity to protect and preserve.
John Simmonds is director of policy, research and development at CoramBAAF
