Babies Dying Amid Agency Failings

Too many babies have been killed or seriously injured through child abuse because of failings by the authorities that are repeated across the country, a report has found.

Ofsted highlighted recurrent patterns of agencies carrying out inadequate pre-birth risk assessments, placing too much focus on the mother's needs at the expense of the baby, and underestimating the vulnerability of young infants.

The regulator also warned that staff were underestimating the risks resulting from the needs of parents with problems ranging from drug addiction to histories of abuse, and said teenage parents in particular were receiving insufficient support.

It cited the case of a 12-week-old boy from the Isle of Wight who suffered 16 separate non-accidental fractures after the authorities failed to consider the dangers posed by his 19-year-old father's history of becoming violent when drunk or his 17-year-old mother's troubled background.

There has been heightened concern about how agencies care for vulnerable young children since the horrific death of 17-month-old Baby P - now named as Peter Connelly - while on the at-risk register in August 2007.

Babies make up a disproportionately large proportion of the youngsters who are the subject of official investigations into the worst cases of child abuse or neglect, known as serious case reviews.

Under-ones accounted for more than a third of the 602 children in England whose death or serious injury was examined by reviews evaluated by Ofsted between 2007 and 2011.

The regulator's new report identifies a series of lessons to learn from these investigations, especially for health workers, who are most frequently involved with vulnerable babies.

In one case a newborn baby in Torbay, south Devon, died six days after being discharged by a hospital at just 13 hours old even though agencies held detailed records about the parents' alcoholism, evidence of domestic abuse, and concerns about the neglect of older siblings.

Another serious case review found that concerns about a baby boy who ultimately died of severe malnourishment and dehydration could have been flagged up if his GP had simply plotted his weight on a chart.

Ofsted's report also looked at serious case reviews involving children over 14, who made up 18% of the total.

It found no clear pattern to these incidents, which featured factors including emotional and mental health problems, homelessness, drug and alcohol abuse, unemployment and troubles at school.

Overall the reviews found that too often agencies treated vulnerable teenagers as adults rather than children, and focused on their difficult behaviour rather than their need for support.

The regulator referred to a case where one teenage girl died and a second was left in a critical condition only days after one of the pair told school staff they had entered into a suicide pact.

Ofsted also published a second report today looking at how local authorities can successfully keep children out of care by supporting families to stay together.

Miriam Rosen, the regulator's chief inspector, said:

 ''These two reports make a significant contribution to our understanding of how to better protect some very vulnerable groups, particularly babies and children over 14.

''Our analysis of the lessons to be learned from the serious case reviews we have evaluated over the last four years reveals recurring themes which contribute to failures to protect children within these age groups.''

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