Review into baby’s death sees Portsmouth City Council criticised

ERRORS Portsmouth City Council accepted it made mistakes when handling the case of 'Child D'
ERRORS Portsmouth City Council accepted it made mistakes when handling the case of 'Child D'

Taxpayers forking out millions in legal costs

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PORTSMOUTH City Council has been criticised in a review into the death of a three-week-old baby subject to a child protection plan.

An inquest found the girl, who can be identified only as ‘Child D,’ died from natural causes due to infection.

But a review following her death in December 2011 highlighted multiple weaknesses in the handling of her case.

This included a breakdown in communication between various agencies involved in Child D’s care.

The review is the second in Portsmouth in 18 months concerning young mothers with several children which highlighted weaknesses in child protection planning.

The council has apologised and said lessons have been learnt.

A raft of recommendations have been made to the council, police, the NHS and other organisations involved.

The review revealed ‘substantial contact’ between the authorities and Child D’s family and that some of her half-siblings had suffered ‘very serious, inflicted injuries’ as young children.

Their injuries were investigated but there was insufficient evidence to pursue criminal proceedings.

After Child D was born, she was made subject to a child protection plan and was living with extended family when she died.

On the night of her death she had been left sleeping in unsafe circumstances, in the care of a ‘vulnerable’ young woman.

No-one was prosecuted as a result of her death.

However the review conducted on behalf of Portsmouth Safeguarding Children Board (PSCB) found social workers managing the case were newly qualified with no experience of child protection and court work.

It said care planning had become ‘confused’ and highlighted a breakdown in the relationship between the family and most of the agencies involved.

The review also found weaknesses in assessments, investigations into ‘unexplained’ injuries to some children in the family and poor quality legal advice from the council.

Julian Wooster, the council’s director of children’s and adults’ services, said improvements have been made.

He said: ‘We fully recognise that the support the council provided for this family could have been better organised and we apologise for this.

‘The action plan we have developed and implemented in response to this review has included increasing the number of solicitors dedicated to child protection work.

‘It also ensures there is close scrutiny of arrangements before a child is placed with a family member.

He added: ‘Here in Portsmouth, despite being constrained by a shortage of experienced social workers nationally, we have recognised the need to make significant changes and have made many improvements to our social work teams.’

Jimmy Doyle, PSCB independent chairman, said: ‘I would like to offer reassurance that the lessons learned during the review of the sad death of this child have resulted in further improvements of services for children in Portsmouth.’


· The board should consider introducing multi-agency quality assurance initiatives directly aimed at appraising how well agencies are working together.

· The board should support the renewed delivery across all partner agencies of initiatives to promote ‘safe sleep’.

· The board should commission a multi-agency review of local practice and arrangements to support child protection agencies in working together effectively outside ‘office hours’.

· The board should evaluate the reports arising from this review of unsatisfactory working relationships between Children’s Social Care services and a school and, if necessary, develop a protocol to strengthen effective communications and understanding of the arrangements for escalating concerns.


· The local authority (Legal Services) must ensure that Legal Services are equipped to provide adequate support to front-line services so that the local authority can meet its statutory responsibilties to protect and promote the best interests of children.

· The local authority (Children’s Social Care services) should ensure that there are clear and reliable arrangements for assessment and follow-up where pre-birth child protection concerns are identified.

· The local authority (Children’s Social Care services) should introduce arrangements in Children’s Social Care services for routine review, above first-line management level, of the progress of cases involving care proceedings.

· The local authority (Children’s Social Care services) should review its arrangements for dealing with ‘kinship care’ placements.

· The local authority (Education services) should remind all schools of the need for high quality recording and record-keeping when they are dealing with the safeguarding of children.


· Cafcass should provide updates through regular attendance and reporting to PSCB on progress it has made in relation to all of the proposals within the Cafcass action plan.


· The Trust must ensure that midwifery services are always appropriately involved in the planning and management of cases which raise safeguarding concerns.