Learning briefing: Ashley – baby with physical injuries

The Incident

• Ashley a 9-week-old infant, resided with their mother, Ashley at their maternal grandparent’s residence during the incident.
• Ashley contacted emergency services (999) after Ashley sustained  burns, prompting the immediate transportation to the Emergency Department via ambulance.
• The severity of Ashley ‘s injuries, coupled with their age and immobility, raised safeguarding concerns.
• Conflicting explanations regarding the cause of Ashley’s injury emerged from their mother and other family members.
• A multiagency strategy meeting was convened to share available information to inform the next steps to ensure Ashley’s safety.
• Ashley received further medical care for their burns at a regional paediatric unit before being discharged into the care of a foster carer.

Good practice

• The midwife conducted routine inquiries into Ashley’s mother’s experience of domestic abuse and took additional steps to ensure confidentiality and assess consent regarding recent sexual activity. This proactive approach aimed to safeguard both Ashley and their mother from potential harm.
• The social work manager demonstrated a high level of scrutiny and challenge in safeguarding Ashley, taking decisive action by escalating concerns to both the police and within their own agency. This proactive response ensured that decisions made at the strategy meeting were rigorously assessed and challenged when necessary.
• The GP exhibited robust record-keeping practices and clinical proficiency in safeguarding Ashley and assessing their mother’s emotional needs. The GP’s thorough examination of Ashley, particularly in response to concerns about their mother’s mental health and parenting capacity, contributed to ensuring the child’s welfare and appropriate intervention.

Messages for practice

1. Effective Communication: Practitioners should prioritise open and frequent communication with each other. This would facilitate the expression of concerns, including “gut instincts,” and ensure clarity regarding thresholds and planned actions among agencies. Additionally, it would expedite the sharing of vital details such as addresses, enhancing overall effectiveness.
2. Timeliness of Police Investigation: Timely commencement of police investigations is critical in safeguarding cases. Delays in initiating investigations, such as the decision not to interview relevant household members and secure evidence promptly, can significantly impact the ability to gather crucial information and ensure swift action to protect vulnerable individuals.
3. Importance of Challenge in Strategy Meetings: Staff involved in strategy meetings must provide appropriate challenge to ensure safety plans are robust and actions taken by agencies are appropriate. Failing to challenge decisions or plans within these meetings can lead to gaps in safeguarding measures and potentially compromise the safety of those at risk.

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