Neglect and serious case reviews (PDF, 735KB) - nspcc

or more of a burden to his mother, or that she could not cope with Ben’s
complex needs as well as the demands of a young baby.
what it was like to be a child in this family:
agency involvement:
learning:
Ben was secure in his mother’s love and interest and he enjoyed and
benefitted from playing with her and singing songs. His life was not always
predictable however and things at home were different when his father
was around, when his mother did not play with him so much and there
were sometimes arguments. When Ben’s baby brother was born things
changed and Ben’s mother had less time for him and forgot to give him his
medication more often. He knew he had to look after himself now and was
on his own more often and didn’t go to the hospital or see the doctor so
often. Without regular medication Ben had more seizures, and in the days
that followed, less energy and more impaired function. Life was harder,
more confusing, and at times frightening.
• gp and specialists: Many medical professionals including specialists
remained involved with Ben throughout his life because of his diagnosis
and saw him frequently in spite of numerous missed appointments.
Although hospital staff were concerned that Ben’s mother was not
managing Ben’s health related needs, they did not refer the case to
children’s social care as they felt the otherwise loving mother was
complying with their concerns and attempting to improve.
• health visiting: Two health visitors were involved in Ben’s life. The
first health visitor observed that the relationship between him and his
mother was warm, and that Ben seemed happy and confident. The
home, although small, was clean and comfortable with adequate food.
Although the relationship between the mother and the health visitor was
initially good, it deteriorated when the health visitor became concerned
about Ben after his sibling’s birth. She discussed involving social care, and
as a result Ben’s mother stopped seeing the health visitor. The second
health visitor did not follow up on her colleague’s suggested referral.
Themes emerging from the serious case reviews included:
3. A thematic analysis of neglect
• undue professional optimism: While Ben received adequate medical
treat ment and was prescribed medication, medical staff did not follow
up his failure to grow and thrive. Even when staff suspected the mother
might not be administering medication appropriately, the case was not
referred to CSC as they wanted to give her more time to improve. The
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