‘Unacceptable’ failures by Scottish agencies risked further harm to baby who ingested cocaine and another with broken bones

There have been a raft of recommendations to tighten-up child protection procedures in Tayside

A series of “unacceptable” failures have been found in the way Scottish agencies cared for a young baby who ingested cocaine and another who was found to have multiple broken bones.

Both youngsters, who were from Perth and Kinross and were hospitalised during Covid-19 restrictions, were said to have been put at “further risk of harm” as result of various problems relating to child protection procedures. The separate cases have led to a raft of recommendations to improve services, the majority of which are directed at NHS Tayside.

It follows a newly-published review into the protection of the two injured children, known as “Child G” and “Child D” to protect their identities.

Ninewells Hospital in Dundee. Picture: Ian Rutherford

Child G was put on the child protection register before being born, and the baby’s mother contacted health visitors and doctors several times with concerns about the youngster’s health following birth.

After being referred to Ninewells Hospital in Dundee, the child was found to be “significantly unwell”, requiring “protracted and difficult” CPR, and was transferred to the Royal Hospital for Children in Glasgow, where they remained “critically” ill.

In Dundee, staff had noticed the youngster’s parents were “smelling of cannabis”, prompting a urine toxicology report for the baby, which later tested positive for cocaine.

A learning review has now found the case exposed problems with local policies and procedures to safeguard youngsters. The report highlighted a delay in police being informed of suspicions the baby had been exposed to drugs, which led to “unacceptable delays in child protection processes, and ultimately put Child G at further risk of harm”.

Paediatric medical and nursing staff did not confidently follow NHS Tayside child protection policies, meaning “concerns were not communicated quickly enough to inter-agency colleagues”.

It was also found the reason the baby was put on the child protection register was not detailed on NHS Tayside’s system. If it had been, doctors may have considered drug exposure “sooner”.

The report said processes for Child G “lacked co-ordination”, and that documentation was “below standard and allowed for misinterpretation of advice in the care of a critically ill child”.

The learning review for Child G was carried out for Perth and Kinross child protection committee (CPC) as part of the same report that looked into the separate case of Child D. The process was led by Dr Marianne Forrester, lead paediatrician for child protection at NHS Grampian.

In the case of Child D, the mother lost her job and faced being made homeless before the baby was born, but no referral was initially made to local housing services or the family nurse partnership.

Following the child’s birth, they were discharged to temporary accommodation. The mother soon reported the youngster was unsettled, there were feeding issues and the baby was “screaming”.

She subsequently called NHS24 services and said Child D had “a hole in their gum extending to the lip and there was blood on the bed sheets”.

The mother told medics the child had caught their gum with their nail a few days earlier. Over the following days the child was seen separately by a trainee GP, a paediatric surgeon, a family nurse, and another GP, but at no point was the injury recognised as a child protection concern.

When the mother reported more blood in the baby’s mouth, a triaging GP recorded it would be “unusual” for the injury to “occur spontaneously”. A visit from an out-of-hours GP was arranged, who did not consider abuse, but referred them to Ninewells anyway, fearing a rare medical condition.

The child was initially discharged from Ninewells after doctors and other child protection professionals discussed the case, but police stepped in and raised concerns. Later that day a skeletal survey found multiple fractures, of differing ages, in Child D’s bones. A review ruled they were consistent with non-accidental Injuries.

While in hospital, the baby was also dropped twice in the space of two hours as the mother fell asleep.

The review noted health staff had not been “adequately trained in recognition of indicators of physical abuse”, with the oral injury a “clear” sign that was “not understood or recognised”.

It said: “Child D was therefore not referred timeously to child protection services, putting Child D at risk of further serious harm.” The report added “ineffective information sharing” resulted in the youngster “not being protected from abuse”.

The initial decision to discharge the child before the skeletal survey had come back was branded “incongruous with child protection procedures”.

Despite the failures, the report also highlights several examples of good practice in the treatment of both children, including the police intervention when Child D was initially discharged.

A total of 22 recommendations were made, of which 16 related to health services, while six were for the CPC.

The review is the latest to be carried out by Perth and Kinross CPC. In 2021, a report found “significant missed opportunities” to protect neglected “Child B”, whose life was only saved when a member of the public noticed their “deathly” complexion.

The following year a review found “fragmented” care for a 17-year-old transgender pupil who took their own life.

Thomas Glen, chair of the Perth and Kinross public protection chief officers’ group, and chief executive of Perth and Kinross Council, said: “Any situation where harm which comes to the youngest and most vulnerable members of our communities is always a matter of concern and requires a thorough and detailed review.”

He said all the recommendations had been accepted and the group had been “assured about the amount of improvement work already undertaken”.

Bill Atkinson, chair of the CPC, said the review required “detailed and sensitive handling due to its complexity”. He said: “It is vital, however, that we continually reflect on our work in child protection to ensure that we keep children and young people safe from harm.”