Independent review finds 'catalogue of failings' by health and social care services in lead up to murder of 11-month-old Callum Wilson in 2011
Death could have been prevented
A CATALOGUE of failings by numerous bodies has been revealed in an independent investigation into the circumstances leading up to the murder of an 11-month-old baby by his mother.
A CATALOGUE of failings by numerous bodies has been recorded in the independent investigation into the circumstances in which an 11-month-old baby murdered by his mother.
The Windsor and Maidenhead Local Safeguarding Children Board (LSCB) today published their Serious Case Review (SCR) into the death of Callum Wilson in March 2011.
His mother Emma Wilson was found guilty of his murder in December last year and sentenced to life behind bars in January to serve a minimum of 14 years.
The report details a series of errors by care professionals and in practice methods by the NHS at Foundation Trust level, by GPs at primary care level and the Royal Borough's children's social and family support services.
Its conclusion found that he could have been saved.
The review states:
- over the long term the potential risks to Callum were underestimated
- when he moved to live with his mother [after spending the first seven months of his life in foster care] he should have been closely monitored because of the concerns about the circumstances of his birth and his mother's failure to visit him for long periods when he had been looked after
- in the two weeks before his death professionals missed opportunities to intervene which, if they had been taken, are very likely to have led to the detection of serious injuries and are very likely to have prevented his death.
Callum was born in April 2011 though Wilson had concealed or did not know that she was pregnant.
Between his mother assuming care for Callum and his death, which was caused by a severe head injury, a social worker, GP, staff at a council children's centre and a health visitor at a child health clinic all noticed bruising or scratching on the baby, but at no stage was this referred on to the Royal Borough's social care team.
When the children's centre sought advice from the council, the centre coordinator spoke to an unqualified member of staff without realising.
Wilson blamed the injuries on falls or on other children.
A post-mortem found Callum had suffered a number of fractures that predated his death by at least two weeks and possibly longer. During that time, there was three occasions in which bruising on Callum was noted or discussed, but it was never referred on to the local authority or was Callum referred on for a paedriatric assessment.
This would likely have led to action being taken to protect him.
Other areas of concern flagged up in the SCR include;
- the issue of concealed or denied pregnancies and that a detailed assessment of Wilson should have been undertaken and greater communication was needed between midwifery services and health staff such as GPs and health visitors to recognise the significance of the concealment with later issues.
- the lack of a social work core assessment for Callum which, while not procedurely necessary once he was no longer a looked after child, the SCR felt professional judgement would have identified the case as a complex one and so requiring a further assessment.
- the transfer of GP records for some family members was 'not fit for purpose'.
- caseloads of health visitors in East Berkshire exceeding nationally recommended levels.
- a lack of staff experience at the children's centre in running and managing a service used by large numbers of children and a lack of training on safeguarding children.
- the inexperience of the newly trained social worker assigned to the case and a lack of high level supervision.
The review makes a host of recommendations for change in practice at NHS Berkshire, the Berkshire NHS Foundation Trust, the Heatherwood and Wexham Park Hospitals NHS Foundation Trust, primary care and the Children's Social Care and Family Support Services at the Royal Borough.
The SCR adds: "Many of these recommendations have already been fully or partly implemented. The LCSB will oversee implementation over the coming months to ensure that lessons are learnt and practice improves."
The LCSB has drawn up an action plan that sets out a timetable for completion for actions and which agency is responsible for seeing their completion.
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