Between June 2024 and August 2024, three serious incidents of parental neglect causing harm to children were notified. Rapid Reviews were undertaken. These cases underscore the challenges in addressing child neglect and the importance of multi-agency collaboration and persistent intervention to protect children’s well-being.
Child 1
A 16-year-old girl with autism and a degenerative eye condition experienced long-term neglect. Concerns included poor hygiene, missed medical appointments, and school absenteeism. In May 2024, a visit revealed neglectful home conditions, leading to the mother’s arrest and the children being taken into care.
Child 2
Five children in Devon showed signs of neglect amidst domestic abuse and substance misuse. Their mother needed to be hospitalised due to complications from surgery prompting services to enter the home and identifying severe neglect. Previous referrals by services were closed due to lack of consent.
Child 3
Two children in Exeter were part of a family known by services due to domestic abuse and neglect since 2006.
Fire safety issues highlighted significant hoarding and led to a multi-agency investigation. Chronic neglect was uncovered, including health service disengagement and physical abuse. Multiple agencies reported unsafe home conditions and lack of engagement with services. Three contacts in 2024 with the Front Door showed a pattern of neglect and refusal to cooperate.
Common Themes and Patterns
- Chronic Neglect: All three cases involve long-term neglect, including poor hygiene, inadequate living conditions, and failure to meet basic needs such as medical care and education.
- Unsuccessful Attempts to Engage: In each case, support services we unable to engage the parents or guardians who often prevented professionals from entering the home or following through with recommended actions.
- Health and Safety Concerns: Each case includes significant health and safety issues, such as untreated medical conditions, poor living environments, and lack of immunisations.
- Involvement of Multiple Agencies: All cases required the involvement of multiple agencies, including social services, health services, and Police, to address the complex needs and risks.
- Missed Opportunities for Early Intervention: There were missed opportunities for early intervention in each case, often due to a lack of information sharing, reliance on parental consent, or failure to fully assess the children’s living conditions.
- Impact of Domestic Abuse: Domestic abuse is a recurring theme, affecting the family dynamics and contributing to the neglect and instability in the children’s lives.
- Professional Curiosity and Persistence: In each case, there were instances where professionals showed strong safeguarding curiosity and persistence, which eventually led to the identification and addressing of neglect.
These patterns highlight the importance of effective multi-agency collaboration, early intervention, and maintaining professional curiosity to safeguard children at risk of neglect.
Common Examples of Good Practice
Professional Curiosity and Persistence:
- Education Welfare Officer contacted medical services (Child 1).
- Primary school showed high levels of pastoral support and professional curiosity (Child 2).
- Hospital staff displayed strong safeguarding curiosity and persistent follow-up (Child 2).
- The Fire Service persisted with the fire safety review and raised concerns (Child 3).
Effective Multi-Agency Collaboration:
- Front Door/MASH process requiring an assessment after three or more contacts within 12 months (child 1 and 3).
- Ambulance Service referral to Front Door and Fire Service identified neglectful living conditions (Child 3).
Supportive School Interventions:
- School provided clean clothes and showering facilities (Child 1).
- Primary school improved attendance with supportive steps like breakfast clubs (Child 3).
Clear Professional Challenge and Self-Reflection:
- Child in need meeting showed clear professional challenge from the school (Child 1).
- Both schools demonstrated good self-reflection and recognised areas for improvement (Child 2).
Prompt and Proactive Actions:
- Social work team attempted a prompt home visit after receiving concerns (Child 2).
- Children’s services implemented a process requiring social workers to seek supervision when families decline engagement (Child 1).
These examples highlight the importance of professional curiosity, effective multi-agency collaboration, supportive school interventions, clear professional challenge, and prompt actions in safeguarding children.
Common Areas for Improvement
Professional Curiosity:
- Over-reliance on parental narratives.
Information Sharing:
- Poor information sharing and lack of comprehensive chronologies.
- MASH process did not seek wider partnership information.
Consent Understanding:
- No partner agency information requested due to lack of consent.
- Consent remains a barrier to effective multi-agency work.
Home Visits:
- Missed opportunities for home visits to observe and report safeguarding concerns.
Decision Making:
- Failing to seek other agency information, critical in neglect cases.
Response to re-scheduled appointments
- Health settings’ policies not triggering necessary review/responses.
Inclusion of Relevant Information:
- Adult mental health information would have been relevant for understanding parental behaviour.
Indicators of Need:
- No defined neglect section in the levels of need tool.
Professional Confidence:
- Professionals lacked confidence in escalating concerns.
Hoarding Guidance:
- Promote and agree on hoarding guidance across agencies.
Graded Care Profile:
- Need to promote training and use of the graded care profile.
Next Steps:
- The three Rapid Reviews met the criteria for full Local Child Safeguarding Practice Reviews and partners have agreed to commence with a piece of multi-agency review work incorporating all three.
- A multi-agency Neglect Task and Finish Sub-Group has been stood up to review the Devon Neglect Strategy and Toolkit. Additionally, the group is working on the recommendations and actions to improve multi-agency practice. More information to follow.
- The Quality Assurance Workforce Delivery Group will share the findings from their deep dive thematic review into neglect in Autumn.
- There will be a number of Best Practice Events in 2025 to help us all share the learning and consider our practice.
What can you do now?
Read & Discuss the briefing in your teams.
Be Curious: Gather information and interact with families.
Avoid System Lead: Be professionally curious regardless of what your organisations systems and processes are prompting you to consider – be tenacious.
Training: Seek out, attend and maintain your training and development.
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