Table 1

Quotes to illustrate the theme of predisposing factors

Vulnerable childrenParents (the mother and step-father) reported finding the treatment very difficult and noted that his behaviour was also extremely difficult. The child was oppositional (refusing to get washed, dressed, eat, do physiotherapy) and they thought he was low in mood, scratching arms, leaving marks and inducing vomiting when distressed (case A).
Parental factors…it is likely that the young person’s mother was presenting the young person’s problems as a proxy for her own emotional distress. What this effectively means is that the professionals were trying to ‘treat’ the mother’s emotional, mental health or personality difficulties through the medium of the young person. This was always going to fail, as this is not an effective way to address the mother’s needs (case B).
Mother can at times manage some of the practicalities of everyday life with regular support from others, especially her mother. At other times, she finds it very hard. Sometimes, during baby’s life she needed daily visits from the family support practitioner to meet the children’s basic care needs (case C).
Chaotic householdConcerns continued relating to home conditions, school attendance and mother’s reliance on teenagers as her main source of support (case D).
Maternal grandmother and mother were also able to use their previous experiences of the system and working with professionals to present with what is often called ‘false compliance’ or provide short-term reassurance rather than long-term sustained change (case C).
Professionals failing to protect childrenA key concern is the omission of the paediatrician in the strategy discussion as it is likely that this would have both occurred face-to-face at the hospital and provided a comprehensive picture of the risks…. The strategy discussion form is brief on detail and lacks analysis on the rationale for progressing to a Section 47 enquiry, this undermines effective risk assessment (case E).
With the exception of early years practitioners, there was insufficient recognition of day-to-day experiences and likely long-term impact of non-life threatening neglect of physical and emotional needs.…The lack of understanding of life in the family from the perspective of the children meant that any analysis of the risk of harm to them was insufficiently informed (case F).