On 10^th January 2014, the then Gwynedd & Môn Local Safeguarding Children Board recommended that an Extended Child Practice Review should be undertaken following the sudden death of a 13-week old baby. The Board sympathise with the family, who have been kept informed at every stage of the review.

The purpose of the Review was to establish whether there are lessons to be learnt about the way in which local professionals and agencies work together to safeguard children, to ensure that the lessons are acted upon, and improve inter-agency working. This Extended Child Practice Review report was sent to Welsh Government in July 2015 and, under the regulations, the safeguarding team can draw in other parts of the Welsh Government and the Inspectorate Group if any further action is needed. No further action was needed.

The inquest into the child’s death concluded that the cause of death was unascertained, but did confirm the existence of a healing fracture to one of the child’s ribs at the time of death. This fracture was not related to the death.

The reviewing team identified that there had been significant breaches of the All Wales Child Protection Procedures 2008, which resulted in missed opportunities for intervention and contributed to delays. In particular, the reviewing team was critical of the number of changes in social workers, which took place at critical times in the child’s life. The reviewing team was also critical of the use of Section 20 as a holding device, which lacked management.

The reviewing team identified that the child was extremely vulnerable and the team concluded that the issue of whether the child experienced post birth drug withdrawal remained unresolved. In the reviewing team’s opinion the circumstances in which the child was placed could and should have been avoided. There are lessons here for all agencies, which include identifying and managing risk; sharing information; understanding the legal basis for intervention; the need to understand the needs of parents as well as those of children; the health needs of babies who may have been harmed whilst in the womb;  and the need to better understand the factors that contribute to sudden death in babies.

In September 2014, the reviewing team met with Anglesey County Council to highlight their early concerns about practice, policy and procedure compliance and to safeguard other children who may share a similar profile to this child.

In April 2015, the North Wales Safeguarding Children Board sought reassurances from Anglesey County Council that there had been progress, and assurances were given in relation to the stability of workforce; risk tools embedded in practice; and audit of Section 20 placements.  Anglesey County Council introduced a number of changes to its practices during the course of the review, ensuring that there was no delay in responding to the lessons learnt. An action plan has been formulated and progress has been reported to the North Wales Safeguarding Children Board in respect of these recommendations.

The report can be seen within the  Child Practice Review pages.

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