This update section is based on the Report of the Caleb Ness Inquiry, chaired by Susan O'Brien Queen's Counsel (QC). This document is in the public domain and, to aid widespread access, a copy of the report has been included here (650Kb PDF file).
On 18th October 2001 Caleb Ness - an 11-week-old baby - was admitted to the Royal Hospital for
Sick Children in Edinburgh (RHSC). He was found
to be dead on admission. As the Report of the
Inquiry into his death shows, Baby Caleb's short
life had been very stormy.
Baby Caleb was born to a mother who had been
a drug addict for twenty-years. She had made
several unsuccessful attempts to overcome the
addiction but was using methadone by
prescription throughout the pregnancy. As well
as being a drug addict, the report makes it clear
that she had "a long history of prostitution" and
"many criminal convictions". She had two other
children, both of whom had been taken into
care. She was known to have been suffering post-
His father was also known to have been associated
with drugs, having been released from prison
on license for drug-related offences in late
summer 2000. Prior to that Caleb's father has also been convicted for the serious assault of an adult.
In between meeting Caleb's mother in the
autumn of 2000 and Caleb's death in 2001, he
had suffered a brain injury. At the time of the
death, his brain injury made him confused and
he was depressed.
Caleb was born with neonatal abstinence
syndrome. This is one of the possible
consequences of drug misuse during pregnancy
which were described in chapter four. Neonatal
abstinence syndrome happens when a newborn
baby is withdrawing from the effects caused by
the mother's drug misuse. Immediately after his
birth on 30th July 2001, Caleb was admitted to
the special care baby unit at the Royal Infirmary
of Edinburgh at Little France (RIE). He was there
for three weeks before being discharged into the
care of his mother.
The findings from his post-mortem showed that
in the seven weeks between coming home from
the RIE and his death in the RHSC, Caleb had
suffered from at least three separate episodes of
trauma to the chest, probably caused by gripping
during shaking. The findings also suggested that
Caleb died rapidly from a brain haemorrhage
following traumatic injury, probably caused by
In February 2003, Caleb's father was convicted of culpable homicide on the grounds of diminished responsibility caused by his brain injury.
After the conclusion of the court case, the Lothian
Area Child Protection Committee commissioned
an Inquiry into the death of Caleb Ness. An
independent QC chaired this Inquiry with support
from both a Community Paediatrician not
involved in the case and an external Social Worker,
both of whom had experience of child protection.
The findings of this Inquiry were made public in
October 2003. The Inquiry concluded that:
"No single individual should be held responsible. We identified fault at almost every level in every agency involved. Many concerned professionals did their best for this family, but too many operated from within a narrow perspective without full appreciation of the wider picture."
The executive summary of the report details a
series of factors that the Inquiry team concluded
had contributed to the baby's death. These may
be summarised as:
- A failure to take into account all the relevant
information which would have helped
professionals make a full assessment of the
risk to Caleb, especially where there were
factors which were the consequence of the
health status of his parents;
- A flawed child protection case conference
process and ongoing problems with
information sharing which meant that Caleb
continued to be at risk, even through he had
been placed on the Child Protection register;
- Differences of understanding about what
constituted appropriate monitoring of baby
Caleb and failures by some individuals to respond
appropriately when the monitoring that did occur
suggested he was at increased risk;
- A lack of senior social work involvement in
the assessment of risk, in the re-assessment of risk, in decision making and in ongoing
- An absence of clear management
responsibility and accountability for child
protection within health agencies and;
- A failure to understand the roles and
responsibilities of others with regard to child
protection. Amongst the services focussing on
children, this took the form of professionals
making too many assumptions of what others
would be doing. On the part of the services
associated with Caleb's parents, the failure
was more associated with a lack of
understanding that they had a responsibility
for child protection. The need for improved
training for professionals was identified.
The Inquiry team made 35 recommendations for
improving child protection processes. Of these,
11 are specifically directed towards the NHS in
Lothian with a further 13 requiring NHS Lothian
involvement. These are detailed on the following
pages (see Box U1).
In collaboration with our Local Authority partners,
NHS Lothian is committed to creating a joint action
plan that will respond positively to each and every
one of the recommendations in the Inquiry report.
It has established a Child Protection Action Group,
chaired by the Child Health Commissioner
Margaret Wells, to develop appropriate actions
to include in the joint action plan. Amongst the
work already put in hand has been:
- Increasing awareness amongst NHS Lothian
about their responsibilities for child protection.
This took the form of both an electronic
briefing to staff and a simple reminder card
included in the November salary advice
(see Box U2);
- Undertaking an audit of all Lothian
children who are on the Child Protection
Register to ensure that they are not at risk from factors identified by the Inquiry team
as being at fault;
- Bringing forward the timetable for
implementing the existing NHS Lothian child
protection training programme and
requesting the Lothian Area Child Protection
Committee health sub-group to bring forward
proposals for extending and enhancing the
training programme across all staff groups
at all levels within NHS Lothian;
- Creating a working party to develop protocols
for sharing information concerning risks to
newborn children identified by obstetric and
neonatal NHS staff. This will include the
creation of a lead consultant for child
protection within neonatal medicine.; and
- Creating a working party to develop protocols
associated with the identification and
appropriate communication of risk to children
arising from vulnerable parents/carers who
are known to adult services. In the first instant
this will focus on people with acquired brain
injury, though it is recognised that this should
be a model which can be used with other
The work needed to address all of the
recommendations will be identified in the final
version of the joint action plan.
||RECOMMEND that the CPCC minute format is changed, so that the Chairperson has an
opportunity and obligation to sign the Minutes.
||RECOMMEND that an explicit discussion and decision as to whether or not the child should be discharged to the care of the parent should always be part of a CPCC for a newborn baby.
||RECOMMEND that a Joint Working Party prepares a Joint Protocol to inform the treatment
and care of babies born with neonatal abstinence syndrome.
||RECOMMEND automatic referral to the Social Work Department of any baby born with
neonatal abstinence syndrome, who has not been identified pre-birth.
||RECOMMENDATION that the Trust organises and funds mandatory child protection
training, as identified by their own specialist.
||RECOMMEND that the Trust carefully reviews its record keeping systems to facilitate
effective sharing of information.
||RECOMMEND that Lothian Primary Care Trust urgently allocates resources and skilled staff
to institute mandatory child protection training for staff at all levels, which must include advice on the extent to which a patient's right to medical confidentiality can be breached when a child is at risk.
||RECOMMEND that the pro forma invitation issued by Social Work Departments throughout
the City should be reviewed, in consultation with the Police, and a new pro forma drawn up, which offers the Police far more information.
||RECOMMEND that the Police review the detail of their approach to physical and sexual abuse in collaboration with Child Protection specialists from outside the Police. Thereafter, we recommend that they re-examine their internal procedures for allocating cases.
||RECOMMEND that a clear understanding is reached between the Police and the Social Workers on information sharing prior to the CPCC.
||RECOMMEND that the Social Work Department refrains from interviewing witnesses where an inquiry has been set up.
||RECOMMEND that the Housing Department of the City of Edinburgh reviews what happened here, with a view to streamlining and supporting applications by people suffering from brain injury.
||RECOMMEND that Lothian Primary Care Trust facilitates the registration with GPs of brain injury patients, with a view to providing them with appropriate care outside the hospital.
||RECOMMEND that the section of the Child Protection Guidelines is amended to reflect the
expectation that health care professionals will notify the social work department if they anticipate there may be risk after birth for a child still in utero, even if it means breaching the duty of confidentiality owed to either mother or father.
||RECOMMEND that a file entry is made when information is shared in this way, and in particular when liaison workers pass that information out beyond the hospital.
||RECOMMEND that the LUH Trust reviews the accuracy of its record keeping for at risk children.
||RECOMMEND that serious dialogue is undertaken to clarify the role of the Trusts' Child
Protection Services within an interagency context.
||RECOMMEND that Lothian Health ensures that its various Trusts fund the training requirements identified by their own senior staff with management responsibility for Child Protection.
||RECOMMEND that the best means of triggering early reviews or immediate action in response to health visitors' concerns be investigated, and improved upon, as a matter of urgency.
||RECOMMEND that steps are taken to clarify when medical duties of confidentiality towards a patient who is caring for a child can be waived.
||RECOMMEND that Children and Families and Criminal Justice social work services review their joint working practices in this area as a matter of urgency.
||RECOMMEND that a checklist of invitees for CPCCs is compiled as an aid for social workers in the future.
||RECOMMEND that all agencies make it a priority to collaborate and put in place effective risk assessment processes to underpin decision making.
||RECOMMEND that the use of Senior Practitioners as Chairpersons of Case Conferences is
||RECOMMEND that formal training in how to chair a CPCC is introduced for all new
||RECOMMEND that the CDPS provides information for the use of CPCCs about the inferences which can be drawn from the factual information they are providing.
||RECOMMEND that Social Workers involved with CPCCs in Lothian are encouraged to refer to the Reporter, where there is a history of previous children who have been taken into care, unless the circumstances are exceptional.
||RECOMMEND that CPCC Chairs, in discussion with the Reporter, agree appropriate referral criteria.
||RECOMMEND that resources are allocated for the employmentand training of administrative staff to take and type up Minutes relating to CPCCs.
||RECOMMEND that the pro forma Minutes are changed slightly, to include a section for
signature by the Chair of the relevant CPCC.
||RECOMMEND that the supervising Senior Social Worker should attend Child Protection
Case Conferences, along with the case worker from the Children and Families Team.
||RECOMMEND that consideration should be given to this model of a "core group", as a
means of developing and implementing the Child Protection plan.
||RECOMMEND that senior managers with responsibility for child protection practice have
appropriate training to discharge that responsibility, in every agency.
||RECOMMEND that the Chief Executives and Medical Directors give urgent consideration
to lines of accountability.
||RECOMMEND that an independent audit of Child Protection cases is carried out.
Some recommendations appear more than once.
More than one agency: 1, 2, 3, 4, 8, 10, 14, 17, 18, 19, 20, 23, 30, 32, 33, 35.
Mostly Social Work: 21, 22, 24, 25, 27, 28, 29, 31.
Mostly Lothian Primary Care NHS Trust: 7, 13, 18, 26, 34.
Mostly Lothian University Hospitals NHS Trust: 5, 6, 15, 16, 18, 34.
Mostly Police: 8, 9, 10.