December 2013
Shocking litany of mistakes over tragic death of Belper toddler Riley Pettipierre
HEALTH staff failed to tell social workers that youngster Riley Pettipierre’s mother was a drug addict.
That is one of the main conclusions of a report released today into the death of the Belper tot.
But authorities responding to the damning findings admitted nobody had been sacked over Riley’s death, blaming instead the failure of “systems”.
The report of a Serious Case Review into Riley’s death carried 12 devastating conclusions about some of the actions of professionals involved in the care of Riley and his mother, Sally Dent, and made 18 recommendations.
The main criticisms included “poor information sharing” between health professionals; a lack of effective recording systems; and failure of drug treatment workers to put Riley’s needs above Dent’s and to assess whether the toddler was at risk.
It said a number of professionals did not comply with the child protection procedures in Derbyshire by referring the family to Children’s Social Care.
Mother Dent and father were jailed in February after they were convicted of the manslaughter of their son, Riley.
The toddler died at their home in Kilbourne Road, Belper, on March 13, 2012 after he drank Dent’s methadone.
She had placed it in a child’s beaker for herself to take during the night. Binfield was convicted of putting the beaker in a place that was accessible to Riley.
Dent was also convicted of cruelty to a child – after it was found that, during the final months of Riley’s life, he ingested cocaine, heroin and methadone. Dent used crack-cocaine and heroin alongside methadone.
Lynn Woods, chief nurse and director of quality at NHS Southern Derbyshire Clinical Commissioning Group, said: “I don’t believe anyone has lost their job – in most cases it is a system failure – individual negligence is not common.”
Ms Woods, speaking for the different health organisations in Derbyshire, said: “A serious case review is not a disciplinary procedure – it’s a reflective looking back and learning lessons. It would be up to the individual host organisations if they thought host disciplinary procedures were necessary.”
The conclusion of the report stated that, if Riley had been referred to Children’s Social Care, it “probably” would have prevented his “untimely death”.
The serious case review revealed that despite the many different health professionals and drugs workers involved in care of Sally Dent, a known hard-drugs user, children’s social care was never informed of Riley’s birth in November 2009.
When it was pointed out that a failure of communication between professionals and agencies is something that has been raised before in reviews of why children have died or been harmed, Ms Woods said there were mechanisms in place, such as audits, to ensure the actions taken as a result of the review were “actually serving to make things better for kids”.
She said: “We know there were issues in this particular case that may have impacted on other children, but steps have been put in place from the serious case review and children should be at less or no risk going forward.”
In this case, when Riley was born, he showed symptoms that could be attributed to drugs withdrawal – under correct procedures, the midwife should have requested a meeting with Children’s Social Care and the health visitor.
This was never done.
When Dent left hospital with Riley, health “professionals did not always effectively share communication with each other”, the report said.
Staff involved in Dent’s drug treatment (her methadone plan) “failed to compare the information she provided about her drug use” with each other, which would have shown she was giving conflicting reports.
The report states there might have been a culture at the drug treatment clinic she attended not to be proactive about referring safeguarding concerns to Children’s Social Care. It said the clinic had made no referrals in 12 months.
But the report does add that Riley appeared to thrive, a positive bond had developed between the mother and child and “they were living in what was seen as a positive and supportive arrangement”.
Ms Woods said she did not believe there was “a culture” among drug workers of not referring to social care but she added: “”We, in this case, fully accept, in health, a referral to social care should have been made”.
During the final 10 days of Riley’s life, police received information about Dent and Binfield and drug-dealing but “they did not connect the couple together as parents or identify they had a small child living with them”, says the report.
Police have now instructed all staff that they must inform the Central Referral Unit, which includes social care staff, when they are dealing with an incident that may affect a child’s safety.
