The widely reported case of the Gloucestershire parents who neglected their children will be the subject of a serious case review.
The accounts of the case in the media seem to suggest that education, social care and health professionals had serious concerns for some time but that no action was taken until eventually one of the children was admitted to hospital with serious nappy rash.
The crucial issue for the serious case review seems to be why matters were not progressed sooner in the light of what now seems to have been clear indications of serious neglect.
There are obvious echoes of the tragedies of Khyra Ishaq, Daniel Pelka and Keanu Williams here. But for all the investigating, reviewing and public debate we still seem to be no nearer understanding why sometimes professionals fail to act despite what seem to be clear indications that urgent action is required.
I believe that reviews of cases like this need to focus on why professionals in some circumstances appear to lose situation awareness. It may be that they believe that other professionals have judged the family’s situation to be acceptable, and therefore reluctantly accept that no further action is required or possible. Or it may be that they have known parents and children over an extended period of time and have become slowly ‘acclimatised’ to poor standards of care, with a series of worrying events having been explained away one by one. Or it may be that they empathise in some way with ‘needy’ parents and so tend to see things from the parents’, rather than an objective, perspective.
One thing that is sure is that unless we try to learn why professionals sometimes do not see what, with the benefit of hindsight, should have been obvious, we will never improve practice. Looking for easy targets and pointing the finger of blame makes learning all the harder.
I hope the serious case review in this case will provide some helpful insights, but I’m not holding my breath …