A SERIOUS Case Review into the death of two-month-old baby Teri-Rae Palmer has highlighted a number of potentially life-saving concerns.
It is despite it concluding there was “no information or evidence” that could have predicted “the tragic outcome”.
The review by the Birmingham Safeguarding Children Partnership says changes to how the child protection agencies operate have been made as a result, to try to protect children in such circumstances in future.
They include that they should no longer take on a vulnerable parent’s word that they are abstaining from previous substance misuse – in such instances where they fail to attend drug-testing appointments.
The review concludes the mother’s failures to attend all her appointments had gone “unchallenged”.
In future, the child protection agencies will be urged to consider treating non-attendance at testing appointments as a positive result.
Teri-Rae had multiple rib fractures prior to her death on January 2 2017.
Earlier this year in April, the baby’s 33-year-old mum Abigail Palmer, from Redfern Close in Solihull, was found guilty of manslaughter and two counts of grievous bodily harm.
She was sentenced to 13-and-a-half years at Birmingham Crown Court.
The independent review commissioned by Birmingham Safeguarding Children Partnership found that: ““There was no information or evidence available to agencies and professionals involved at the time which would have led them to be able to predict the tragic outcome in this case.
“The mother must take full responsibility for the tragic death of her baby.”
Teri-Rae was subject of a multi-agency Child Protection Plan from birth. This was due to concerns over her mother’s past parenting difficulties, problems with alcohol and substance misuse, and previous abusive relationships.
During her short life she was seen frequently by health and social workers in Birmingham and Solihull, and was consistently viewed as making good progress and being well cared for.
Teri-Rae was last seen by a social worker on Friday, December 30 2016 when an unannounced visit was carried out.
Initially the baby’s death wasn’t believed to be suspicious as there were no signs of injury and Palmer claimed she awoke on the settee next to Teri-Rae on the afternoon of January 2 2017 to find her ‘blue and lifeless’.
But an investigation was launched days later when a skeletal survey revealed three healing rib fractures – and a later forensic post-mortem confirmed the baby didn’t die suddenly but over a period of up to three hours when her brain was starved of oxygen.
West Midlands Police had turned to micro-CT scanning experts at the University of Warwick in a bid to get a more detailed picture of the child’s injuries.
And the 3D images – 1,000s of times more enhanced than traditional hospital CT scans – revealed further tiny hairline fractures to the girl’s ribcage.
Medical experts concluded the injuries would have shallowed Teri-Rae’s breathing due to the pain and slowly she would have suffocated.
The purpose of the Serious Case Review was to establish whether any lessons could be learnt by multi-agencies safeguarding professionals working with families to help ensure children are better protected in future.
Penny Thompson CBE, Independent Chair, Birmingham Safeguarding Children Partnership, said: “Nothing can change the dreadfully sad outcome for Teri-Rae.
“However, as with all such cases, organisations and professionals involved are determined to learn from these events. As a Safeguarding Partnership this is one of our main purposes, with all organisations acting quickly to implement the learning from this case. We have already made a number of positive changes to improve partnership practice and cross-boundary transfer arrangements.
“This tragedy underlines the challenge that professionals face in establishing relationships with vulnerable people, especially those who have addictions, with the purpose of helping them to become good parents.
“Professionals have to establish trust and yet remain curious, sceptical even, always clearly focussed on the needs of the dependent child, especially one so young.
“Professionals working with parents who have addictions cannot rely solely on assurances of abstinence but should seek evidence of positive change.”
If you are concerned about a child living in Solihull, please ring the Multi-Agency Safeguarding Hub (MASH) on 0121 788 430.
