Case No. EWFC-47

28.After O’s tragic death there was an investigation (A Child Death Review) which culminated in a meeting on 3rd November 2020 which included the Consultant Paediatrician, Health Visitor, Names nurse for Public Health Safeguarding, the Team Manager of the First Response Team and Children’s Services and a Detective Sergeant from Avon and Somerset Police. Information about the family and medical background from further sources such as the family GP was also presented to the meeting. The mother gave a statement to the police shortly after O had died, setting out events in the days and hours beforehand. The metaphyseal fracture had been discovered and so a decision was made that there should be a forensic post mortem. There were no other concerns about the family.29.It was not until May 2022, some eighteen months after O died that the post mortem report was received, with the dating of the fractures. By that time the mother was pregnant with S, who was born in August 2022. In the intervening time the social worker reported that there had been no concerns about the care being given to B by the mother or by the father (who is of course her stepfather).30.A parenting assessment was commissioned, with a report being filed in February 2023. This is a carefully written and thorough document. I think it is fair to say that the author did observe some tensions in the family dynamic, and she was also concerned about the relationship between the father and B, his stepdaughter. She felt that B was invisible to him and recommended that the case needed to be reviewed not just from S’s perspective but also from B’s. She felt that B’s needs have been overlooked. As to the tensions between the parents, the assessor considered that they demonstrated a fragility in their relationship with different parenting styles and assumed gender roles which they had not communicated between them. She recommended that they receive direct support and modelling to understand what it means to be in rhythm and tune with S as the mother has a somewhat ‘romantic’ view of being a parent and the father’s approach is somewhat simplistic.31.There have been some tensions between the parents in relation to the father going drinking with friends and not changing dirty nappies. The mother has been doing the lion’s share of the care of the children and managing the home whilst the father has been out working. The assessor watched some interaction between the parents and S and thought there was a mix of over and under-stimulation, mostly from the father.32.In this case the local authority arranged for the parents to be able to stay in the family home with both children with 24 hour supervision from agency workers. This means that the parents have been observed constantly with the children for a period of about six months. The observations have been almost uniformly positive. Despite the stress that must come with having people living and observing in the family home all the time there has never been an occasion when anyone has expressed any concern that either of the parents were rough or impatient with either S or B. Indeed there is no evidence of any anger or aggression involving either parent or the children at all. The height of any problems are as identified by the parenting assessment. There was an anonymous allegation made in February 2021 but these were not supported by independent evidence.33.It is important to put all these observations together. The more detailed parenting assessment prepared by the social worker identified areas of tension and matters that could and should be worked upon; but the issues that were raised are not necessarily uncommon in families and would not attract the attention of the professionals.