Derbyshire Safeguarding Children Board Serious Case Review - ADS14

This overview report summarises the findings of an independently led Serious Case Review (SCR) commissioned by the Chair of Derbyshire Safeguarding Children Board (DSCB). It concerns Polly, described by her family as a beautiful girl with an infectious smile, twinkling eyes and a bubbly personality, a gentle and loving little girl. Polly and her family are from a white British background.
This (SCR) was conducted in accordance with Government statutory guidance entitled 'Working Together' following Polly's death on the 1st May 2014.
Throughout Polly's short life, there was regular multi agency professional involvement. She was placed on a child protection plan (CPP) because of pre-birth concerns about possible neglect in July 2012, and remained on this plan until the commencement of care proceedings in May 2013 when she became the subject of an interim supervision order and then an interim care order. The outcome of these proceedings was a supervision order made in October 2013.
On May 1st 2014, the local Ambulance Service attended the family home and on arrival found the mother’s boyfriend (B2) giving cardiac massage to Polly; she was reported by him to have ‘gone floppy’ and had stopped breathing. She was taken by ambulance to Queen's Hospital Burton where, after further attempts at resuscitation, she was pronounced dead. The mother (M) and B2 were subsequently arrested and later charged with her murder.
On the 11th April 2016, M was convicted of murder and child cruelty and her boyfriend (B2) of allowing the death of a child. As a consequence of the court convictions and new information that was given in evidence at the trial, DSCB asked the lead reviewers to complete the overview report taking account of this new information. M subsequently appealed against her conviction and sentence duration. Her conviction was upheld but her sentence was reduced.
This case has received significant media attention and quite rightly, there is a need to understand more about the quality and effectiveness of multi-agency practice with Polly and her family, leading up to her death. However, it must be remembered that SCR's, as stated in statutory guidance (Working Together 2015, HM) are primarily about learning and improvement, not blame. This SCR identifies some key themes for learning and improvement through an appraisal, analysis of practice, in light of what was known at the time, and the subsequent information received following the criminal trial.