Minister orders council probe after child deaths

An independent review will be launched into children's services at a local authority after the deaths of seven children in the area, it emerged today.

Ministers are sending in an "diagnostic team" to Doncaster Council, whose children's department was recently slammed by inspectors.

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Serious case reviews have been ordered into the seven children's deaths in Doncaster area. The findings of three have already been made public and involved toddlers aged less than one year old who were abused or neglected before they died.

Last month the education watchdog Ofsted rated Doncaster's children's services as "inadequate".

Children's Minister Beverley Hughes has written to Doncaster Council to express her concern about the situation.

She said in her letter: "I was very concerned to see that inspectors have raised a number of very serious issues about services for children and young people in Doncaster.

"In particular, I note that they judged as inadequate 'staying safe', 'enjoy and achieve', and 'achieving economic well-being', as well as Doncaster's capacity to improve and its overall provision of children's services.

"It is crucial that the root causes of these failings are fully explored and that the capacity and capability of the Council and its key partners to drive improvement in these areas is fully assessed.

"I have therefore instructed my officials to commission a thorough diagnostic review to evaluate the current position of the council's provision of children's services."

At the time of the Ofsted inspection, the mayor of Doncaster, Martin Winter, agreed his authority had experienced difficulties. He said millions of pounds were being injected into the department and all its systems were under review.

In the three serious case reviews already published, it was found there were a series of missed opportunities for social workers to intervene before the deaths.

Serious Case Reviews are undertaken when a child dies, and abuse or neglect is known or suspected to be a factor.

The deaths in the three published cases happened in October 2004, May 2005 and December 2007. The children were aged three months, seven months and 10 months respectively.

In the first of the three published cases, involving a three-month-old baby who died in October 2004, the serious case review said he died of sudden infant death syndrome associated with co-sleeping.

The baby was the youngest of four siblings and the report said: "His parents had been involved in a longstanding relationship punctuated by significant periods of instability, marital violence and alcohol misuse, particularly latterly by mother."

The family came to the notice of the East Riding, then Humberside, Social Services Department in 1992 over concerns about their first, then second, children.

Care orders were granted over the two in 1996 but, after "real improvement", social services involvement stopped in May 2001.

Several years later, the baby involved - the mother's fourth child - was born prematurely in July 2004 after the family had moved to Doncaster.

He was found unconscious in bed on October 21 2004 by his mother, who had been sharing the single bed with the baby and his older sibling. The four-month old was later pronounced dead.

The serious case review said that between September and October his mother showed a failure to keep appointments or "attend to immediate medical needs".

"It should be noted that neither the neo-natal nurses nor the health visitor had a family history to hand as this was contained within Social Services and Youth Offending Service files," the report also said.

It said the child's death was a "tragic accident that occurred when mother and child were co-sleeping" but the report found failings in the way the family had been dealt with.

It said "referral thresholds" were too high and communication between childcare teams and the Youth Offending Service, involved with the eldest child, was not robust in identifying vulnerabilities.

Records on the family were not passed on quickly when they moved into a new area and there had been a failure to ensure neo-natal staff had background knowledge on the family.

In another case of a seven-month-old girl, born in October 2005, the published serious case review said that despite the mother's numerous problems, including alcohol misuse, agencies involved in her pregnancy had not referred her for a pre-birth assessmment.

The report said after the 22-year-old, known as M, gave birth, "midwifery and health visiting services were of the view that (the baby) was appropriately cared for and had no concerns about M's parenting".

The mother was prescribed anti-depressant medication in May 2006 for post-natal depression.

Between March and May three referrals regarding alcohol misuse were received. In one, she was found drunk in bed with the baby.

In May 2006, the young mother found the girl in an unresponsive state, and the girl died later that day.

The report said it was confirmed that mother and baby were in bed at the time of the death.

The report said: "Whilst the cause of death was recorded as sudden infant death syndrome, the coroner expressed the view that alcohol was a contributory factor.

"Despite M's long history of alcohol misuse, alcohol-related crime, 'suicide attempts', history of social phobia, anxiety, bulimia and depression and sporadic engagement with services, the two agencies involved when her pregnancy was confirmed did not consider referring her ... for a pre-birth assessment to be undertaken.

"Vital information about M's past history of depression and suicide attempts was not included in midwifery records.

"There was no direct communication between relevant professionals such that a crucial opportunity was missed to undertake a pre-birth assessment."

It said on one occasion, after receiving a call from M just before 1am on April 11 2006 when she had been drinking, social services did not visit until the following day.

On May 2, after the mother was found drunk in bed with the baby, action was only taken to protect the child for one night.

The report said a pre-birth assessment would have analysed the needs of the child and its parents' ability to respond.

It said: "It should have identified the unborn baby as being at the very least a child in need but possibly one in need of protection whose name may have been placed on the child protection register at birth.

"Whilst alcohol, neglect and co-sleeping arrangements were all contributory factors in the death of AO6, an equally significant issue was the need for improved communications and information sharing within and between professional agencies."