A baby tragically died at less than one month old shortly after a meeting showed ‘no real improvements’ in her home following neglect concerns.
Mia, whose name has been changed to protect her identity, was on a child protection plan when she died and her cause of death is not known.
However, toxicology tests, which checked for drugs or other chemicals, were negative.
Mia’s mother had been struggling with depression and finding it hard to cope with her large family. Despite being on a drug treatment plan, Mia’s dad continued to abuse crack cocaine and heroin.
Conditions at her home in Teesside were described as “extremely poor” and her siblings were often “dirty and dishevelled”.
A review into the tragedy has also exposed how the covid pandemic severely hampered efforts to protect children - with social workers only able to make checks through a window.
Mia’s family was not well known to professionals in Middlesbrough as they only moved into the area in early 2020, report Teesside Live. However, by March 2020 a child protection plan was made for Mia’s older siblings, before her birth.
The report by South Tees Safeguarding Children Partnership states: “It soon became apparent that there were indicators of neglect of the children in this large family…The concerns were specifically about the impact on the children of Mia’s father’s significant and long-term substance misuse and the ability of their mother to protect them from the effects of this.”
The report has not shared how many children Mia’s mum has so the family’s identity is not revealed but it is “much higher than average”. Following an Ofsted inspection in December 2019, Middlesbrough’s children’s social care services were rated as “inadequate”, however, a monitoring visit in December 2021, found that “stronger practice” is now in place.
Though there was concern that too many children still face delays meaning some remain in inadequate situations for too long. Another update from Ofsted is expected next week.
The family moved into Middlesbrough at the start of 2020 and a strategy meeting in February 2020 made health professionals aware of the neglect faced by Mia’s siblings. At this point, Mia’s mum was pregnant with her. Prior to the meeting, children’s social care had received four referrals in around three weeks.
Detailing the referrals, the report states: “Firstly from the police regarding one of the older siblings being out in the community unsupervised late at night. Secondly from Change Grow Live in regard to mother being pregnant and the father having on-going substance misuse issues.
“Thirdly from the school of some of the older children stating that they were unkempt, tired and often absent. Lastly from the ambulance service sharing their concerns about the eldest sibling who came to their notice due to issues of anxiety and anger control, their concerns about the home conditions and the child having responsibility for his younger siblings.”
As a result, Mia’s older siblings were all subject to child protection plans for neglect. Part of the plan included the monitoring of the children’s home and life experiences, however, the start of the covid pandemic inhibited how successfully this could be carried out. Mia’s mum exercised her right to keep her children at home and refused to send them to school, stating that the family was all shielding.
The report states: “The social worker described having to view the home and see the children through a downstairs window.” Despite covid delays, a pre-birth child protection conference for Mia was also held where she became subject to a child protection plan as there was a significant concern of “neglect from birth”. At this point, it was suggested that there had been little improvement in the state of the house with the conditions described as “extremely poor”.
Soon after Mia’s initial conference, a review child protection conference was held. The report states: “There was concern voiced that despite nine months on a plan there had been no real improvements for the children, particularly in regard to their supervision, school attendance, physical appearance and home conditions.
“Their mother had received some parenting work with a resource worker, but was reported not to engage with what was asked of her and often said that she was confused about what she had been asked to do, or that she did not have time to do it.” The chair of the meeting suggested that a legal gateway meeting should be considered if there were no improvements at the next meeting.
The report adds: “There was no clarity regarding what these improvements were and how positive change would be measured however, and with the absence of an outcome-focused plan and no evidence that any neglect tools were used, this was going to be difficult.”
Shortly after this meeting, Mia died.
The covid pandemic created extra barriers for agencies to be able to monitor Mia’s family. In the first few weeks of the lockdown, a meeting that was set up after Mia’s siblings were made subject to a child protection plan, was cancelled. However, there is no evidence to suggest that a new date was chosen.
The report does say that there were “a number of attempts” by the social worker, health visitor and school nurse to see the children, despite the restrictions. Initially, the social worker was only able to see the children through the window due to lockdown.
The report states: “This means that the issues that had been identified at the initial child protection conference, which included the poor home conditions, the children dirty and dishevelled and the children’s health needs not consistently being met, could continue without any meaningful oversight from professionals. Shortly afterwards home visits did start again, but just 15 minutes in the home was recommended following a risk assessment.”
During this time, the children were out unsupervised and one of them was even hit by a car when they were out alone on their bike. The social worker and health visitor kept in touch with the family and did draw up a safety plan.
Speaking about the challenges during the pandemic, Mia’s health visitor stated that there were high workload demands with child protection and child in need families, a lack of staff across the health visiting service, and an increase in safeguarding cases in Middlesbrough. The report adds: “She [health visitor] did not seek safeguarding supervision on this case due to the general pressures and lack of time both to complete supervision forms for all the children and to attend the actual supervision meeting.”
Since Mia’s death, there is now 1:1 supervision to all 0-19 practitioners in Middlesbrough over a three-month period. During the covid lockdowns, Mia’s older siblings all had the option to attend school as they were classed as vulnerable, however, one of the older children didn’t want to go as she claimed it would make her stand out as a child with a social worker.
Mia’s mum chose not to send the younger children either and claimed they were “shielding”. The report states: “The professionals involved thought this was really due to her not having to be organised to get the children to school, bearing in mind her pregnancy and the size of her family.
“For a family where school attendance had been a long-term issue, the pandemic gave a valid reason for the children to miss school. Most schools took some time to set up virtual learning, and it is not known what home schooling Mia’s siblings had in these months.
“Those involved at the time reflected that it was unrealistic to think that a family with so many children, in small and inadequate housing that was often described as ‘unsafe’, with additional social problems could actively learn and develop via home schooling.”
The school did carry out home visits and provided lunch which was recognised as good practice.
The relationship between Mia’s parents was one of the reasons which sparked concern for the care of the children in the first place. Mia’s parents’ relationship was relatively new and her dad was not the father of Mia’s mum’s other children though he does have older children in the area, but does not have any contact.
Mia’s mother said she was suffering from depression following the breakup of a long-term relationship and this was still an issue when the family moved to Middlesbrough. Mia’s mum was also said to be “stressed and frustrated” with Mia’s dad’s drug use.
While she claims that she never gave him money to spend on his drug habit, the pair had a joint benefits claim. It is thought his drug use cost at least £120 per week. Mia’s dad had a difficult childhood and started using drugs when he was just 12 years old – he had physical health issues, an ongoing drug addiction and required a lot of support.
The report states: “There were occasions known to professionals where one of the children would be sent out with mother’s partner to ensure he did not use drugs.” By the time Mia was born, her mum had asked her dad to move out after substance testing showed that he’d continued taking drugs.
This made the professionals involved optimistic that they would break up permanently, however, he was back at the family home after the birth and this was challenged directly with him and Mia’s mum by professionals. The report states that this showed good practice by the agencies involved.
The independent chair of the South Tees Safeguarding Children Partnership (STSCP), Edwina Harrison, said that learnings have been highlighted for all agencies involved.
She added: “Staff in these agencies successfully provide help for hundreds of children and young people every day, and a huge amount of work went into trying to reach the best possible outcome in life for Mia. This report looks in great detail about what happened and why that work did not have the effect that was intended.
“Safeguarding is never straightforward and the report has highlighted a number of learning points for all agencies involved in this and similar cases. It is important that these changes take place as a matter of urgency and that we can be confident that we have better care and support for vulnerable children and their families.
“We can never be complacent when it comes to helping those most in need. I would also like to take this opportunity to appeal directly to those families who are in need or who know of anyone in that situation to seek the help and support that is available and so that we can help them to protect children from harm.”
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