A 19-month-old baby almost died after suffering hypothermia, malnutrition and severe dehydration, 19 days after social services closed her case, an investigation has found.
In February 2025, the little girl was taken to hospital and noted to be ‘incredibly emaciated’, weighing just 4.4kg – more than 5kg less than average for an infant that age. A review found concerns of neglect for Child K1 were raised on three occasions in the lead up to the hospital admission.
But Rochdale social services decided concerns about Child K1 didn’t meet the threshold for a formal child protection investigation. Now the council says it will ensure staff follow procedures around gathering and sharing information to improve care for vulnerable youngsters.
Critical Condition on Admission
Describing the girl's condition upon being admitted to hospital, the Child Safeguarding Practice Review (CSPR) report read: “Child K1 was found to have paper thin skin and there was generalised severe muscle wastage. There was no fatty tissue noted on Child K1’s body.
“There was wasting to the buttocks and pressure sores extending along the spine down to the sacrum and across the bony prominences of the sacrum and hip bones on the lower back.
“Child K1’s presentation of hypothermia, hypoglycaemia, severe malnutrition, dehydration along with renal failure, evidenced by severe abnormality of blood salts, could have led to death if it had not been identified and emergency treatment initiated.”
History of Missed Appointments
Concerns of neglect were initially flagged in April 2024 by a family member. They told hospital staff the mother was asleep on the sofa whilst Child K1 was left unattended upstairs crying, according to the CSPR report. This came after a number of missed check ups and GP appointments by the mother both during and after the birth in June 2023.
The mother accepted some support in April 2024, but health visitors noted that the grandmother was reported to be providing ‘a lot of care’. A second referral was received anonymously soon after, but no action was taken as the mother had consented to work with the family hub. The family worker was unable to contact the family but a health visitor was due to see Child K1 that day.
A string of missed appointments and lack of engagement with social services was highlighted. However, a health visitor in September 2024 noted no significant health or safeguarding concerns. Following that check up, Child K1 was not brought to a physiotherapy appointment and was discharged. Health visitors identified no further intervention was required.
Further Reports and Missed Opportunities
In mid-December, another anonymous report of concern was sent to the Early Help and Safeguarding Hub (EHASH). The report stated: “Child K1’s hair was matted, Child K1 had a bottom sore, was leaking wax from ears, had thick cradle cap, dirty fingernails, was underweight and Child K1’s clothes were dirty.”
The EHASH was then told by social services that the toddler had not been seen since September 2024 and had no allocated social worker. A home visit followed where the little girl was noted to be ‘under weight, had a nappy rash and long dirty fingernails’. The mother was upset by the referral and refused to engage, not responding to numerous calls between January 7 and January 21, 2025.
After this, a strategy meeting was called to decide whether a formal child protection investigation (section 47) should be launched. But the case was closed with no further action as the threshold wasn’t met. Nineteen days later, Child K1 was admitted to hospital in a critical condition.
Mother's Background and Systemic Failings
The report noted the mother was still a child (under 18) when she was pregnant and had been a victim of domestic abuse in 2021. Concerns of potential sexual exploitation were also raised. In the initial social services visit, the mother’s childhood trauma, mental health and potential learning needs were not explored.
The review found services were not ‘sufficiently curious’ to establish who was part of the family network and who was providing care, which could have ‘alerted professionals to the extent mother was abdicating responsibility for Child K1’s care’. A lack of information sharing between midwifery and social services, and gaps in health assessments, also contributed.
The CSPR concluded: “Making a decision not to proceed to section 47 enquiries based on partial information proved problematic. Those attending the strategy meeting did not have complete information in relation to signs of neglect.”
Recommendations included more professional curiosity, more supervision when parents do not engage, more emphasis on historic family information, better information sharing, and establishing the root cause of faltering growth.
A spokesperson for Rochdale Borough’s Safeguarding Children Partnership said: “We accept the findings of the recent review and are taking action to ensure existing policies and procedures are followed by all professionals to ensure the safety of our children and young people.” Child K1 survived thanks to emergency treatment. No further information was shared about her circumstances or her mother following the admission.
