IT is the damning report into how a two-year-old child was left seriously ill after drinking methadone and was failed by a multitude of agencies that were supposed to be protecting her.
The youngster was left living with a heroin and crack cocaineaddicted mother, Kelly Cooper, who had problems with alcohol abuse, in a household riddled with domestic violence.
Nobody will ever know exactly how the child came to swallow the toxic drug, used to help addicts wean themselves off heroin, but she is thought to have picked up a bottle from the waste bin.
Shortly afterwards she was rushed to hospital with a wheezy chest that turned into breathing difficulties. She was drowsy and disorientated, yet her mother could not explain why.
The potentially fatal incident happened in March last year – two months after Miss Cooper’s boyfriend, Ashley Russell, died from overdosing on methadone.
He lay dying for five hours at the bottom of the stairs in the house, with Miss Cooper, now 32, “too hungover, lying around in a drunken stupor” to notice and call for emergency help. Despite those shocking details, still nobody intervened and saw that the little girl and her elder sister, aged six, who were both already the subject of a council child protection plan, were in danger.
Both girls have since been removed from their mother.
Today some 13 organisations, including police, council and health services in Southampton, have been criticised for a catalogue of failings revealed in a report into the child’s welfare.
The serious case review, chaired by an independent adviser and written by an independent author, described the situation as “an accident waiting to happen” and said it would have taken a child to come to serious physical harm before anybody acted robustly.
The Daily Echo understands that some agencies involved hoped that it would not be made public. When it was released, it was published in a summary on a website. It revealed how:
- The two sisters had been allowed to live with their mother even though two older siblings had already been removed and taken into care.
- The entire family was known to several agencies who were concerned for the children because of neglect.
- Their intervention, when it happened, focused too much on Miss Cooper and not her children.
- All agencies ignored evidence from previous court proceedings that showed it was a case of “chronic neglect”.
- GPs who saw Miss Cooper and the children should have played a crucial role – but did the least.
- Police knew the history and the criminal behaviour of Miss Cooper but failed to see the risk to the children.
- Care workers visiting the family home didn’t know how to identify methadone.
The failings were so great in number and widespread that no one person has lost their job or been disciplined.
The report, which has taken around a year to compile, was released this week with a total of 137 recommendations for improvement.
In its key findings about what went so wrong that could have cost a child her life, it said that assessments in this case “lacked a child focus” and centred on Miss Cooper’s capacity to parent rather than the impact of her behaviour on her little girls.
It said that had it have been done properly, they would have noticed her “inconsistent care and neglect” of the children – factors that required rigorous monitoring.
Looking at the role GPs played, it continued: “They were the professionals who received all the information about the parents and the children and were the least practised in assessing the impact on the children.”
- Improve or else, failing agencies warned
- Real prospect of safeguarding city's children
- Agencies must act swiftly
- Read the full report into the case
- Catalogue of failures left vulnerable child in danger
- Warning signals at inquest
The report then criticised police for knowing about domestic violence in the family, the drug and alcohol abuse and criminal behaviour, saying: “The lack of join up between these areas of work ensured that they failed as an agency to properly identify, assess and respond to the risk posed to these young children by the criminal and violent behaviour of their parents.”
Talking about city council care workers who visited Miss Cooper’s home, it went on to say: “The lack of clarity by workers visiting the home about what methadone looked like and the arrangements for safe storage and disposal did not provide any sort of safety net.”
Concluding the investigation, it said; “The pattern of chronic neglect in the family and the agencies’ pattern of responding to individual incidents does suggest that the sad event was an accident waiting to happen… it seems inevitable that only evidence of physical harm to one or other of the children was going to prompt a robust response.”
The review listed a total of 137 recommendations – 32 made by the agencies involved after internal reviews. The remainder include particular points that must be addressed by the police, city council – responsible for social care, education and drug action teams – plus doctors, mental health teams, South Central Ambulance Service and Southampton University Hospitals Trust.
The agencies have been told the impact of the review will be evaluated in six months time.