A badly neglected 17-month-old was only taken into care after a contractor reported seeing him in a cot “with his arms taped”, a report revealed.
The Northamptonshire Safeguarding Children Partnership (NSCP) identified “significant deficiencies in professional care”.
It said “a number of authorities failed to take timely action”.
NSCP said professionals learned from the issues raised in the review.
The review, released Tuesday, said professionals “failed to recognize the warning signs that a vulnerable child was the victim of severe neglect.”
No further action was taken until the contractor’s concerns were reported to social services by a housing officer.
This comes after months of visits from health visitors, social workers and intermittent visits to clinics, who found the child was “losing weight”, “showing no response to being placed back in his crib wide awake” and was “unable to.” standing,” says the report.
A full skeletal examination later revealed the child had suffered five fractures, including fractures in both legs.
The report states: “The question must be asked whether the reason why the child did not pull himself up, stand or walk was because he had suffered two broken legs.”
The child – referred to in the publication as Child Au – who cannot be named for legal reasons, is now safely housed in foster families.
Both parents have since been convicted in connection with the case.
Despite concerns about maternal development, weight and care, two health visitors did not make a referral to the Multi Agency Safeguarding Hub (MASH).
“As a result, Child Au remained at risk of serious neglect and significant harm,” the report said.
According to the report, two of the health visitors believed that a referral to MASH “would not be accepted,” influenced by their previous experience of rejected referrals.
Months later, a contractor visited the home to carry out work and reported seeing “dirty diapers and moldy baby food jars lying around.”
As a result, a housing officer paid an unannounced visit to the home and saw the child upstairs in a cot on a “bare mattress, with no sheets or blankets.”
The child was seen “wearing a baby onesie with her arms ‘taped’.”
A social worker visited the home a day later and found that “there was no food in the cupboards or fridge for Child Au, no toys visible, and no bedding on the cot.”
The protection report states: “Given the strong evidence of neglect, the lack of immediate child care action to initiate child protection proceedings raises serious questions of professional judgment.”
Shortly after, the child’s father told a social worker the child had had a “swollen arm” for several days but was “not sure how that could have happened”.
When the child was taken to an accident and emergency room, an x-ray revealed a fracture in the left arm and a skeletal exam revealed five other fractures, all in varying stages of healing.
When weighed, it was found that the child weighs only 7.3 kg.
The report said the social worker would “take immediate action … to ensure Child Au was medically screened.”
Concerns, previously raised by the contractor and a social worker the following day, should have led to “the convening of an interagency strategy meeting”.
It also said there had been “frequent turnover of social worker” and “a lack of oversight by management … resulting in Child Au suffering significant harm.”
NSCP made a number of recommendations, including that all professionals working with children should read the report “to remind them that observing and recording signs of neglect and abuse is not enough”.
“Action is required if children are to be protected from significant harm,” the recommendation reads.
It is a “deeply sad case” but the child is “beginning to blossom now with foster parents”.
“Significant insights have been gained by professionals since this review began, and we hope the recommendations in this report will help improve practice in very challenging cases like these.”
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