Infants: learning from case reviews Summary of risk factors and learning for improved practice around working with children aged two and under

Girl sat on sofaPublished case reviews show it can be difficult for professionals to find a balance between supporting new parents and recognising and addressing any risks posed to babies. If parents are particularly vulnerable or are experiencing multiple challenges, this can overshadow the needs of very young children. Professionals need training and support to understand how parents’ behaviour can affect a baby in the long term and to be confident in challenging parents if necessary.

The learning from these reviews highlights that professionals should work together to maintain a focus on the needs and experiences of very young children in vulnerable families.

Published: March 2018 


This briefing summarises the learning from case review reports. It is an analysis by the NSPCC Information Service, highlighting risk factors and key learning for improved practice.

Reasons case reviews were commissioned 

This briefing is based on learning from case reviews published during 2017, where children aged two or under were the subject of the review.

The young children in these case reviews faced a complex and wide range of risk factors. They became the subject of reviews following:

  • death or serious harm following abuse (including non-accidental injuries);
  • death following concerns about neglect;
  • death at the hands of a parent who also ended their own life;
  • accidental death associated with concerns about co-sleeping;
  • accidental death associated with concerns about domestic abuse, parental substance misuse and/or parental mental health problems.

Key issues around infants in case reviews

  • Parents who may need extra support to care for their baby and keep them safe include:
    • parents with mental health problems;
    • parents with substance misuse problems;
    • young parents;
    • adults with learning disabilities;
    • parents who have experienced abuse;
    • women who asked for a termination during their pregnancy, if the procedure was not carried out (for example if the request was made too late).
  • Parents who are in an abusive relationship may not realise they are being abused. As a result they may underestimate the effects on themselves and their baby, which can have an impact on their ability to keep their child safe.
  • Domestic abuse poses a significant risk to a baby’s wellbeing. Professionals do not always understand the dynamics of domestic abuse and how it affects very young children.
  • Some vulnerable parents who are able to care for their baby with support from family members or professionals may not be able to sustain the level of care their child needs when they are on their own.
  • Sometimes babies are not allocated a social work practitioner to assess their needs, because their parents are already known to services. This may mean that the baby’s needs are overlooked.
  • When providing holistic support to vulnerable families, professionals may focus on supporting parents and older siblings who are able to communicate their own needs. This can mean that safeguarding risks to babies in the family are not identified or prioritised.
  • Sometimes professionals’ commitment to working with and supporting parents means they don’t arrange multi-agency meetings to discuss the case without parents present. This may mean risks aren’t analysed thoroughly, individual practitioners lack professional support and there aren’t enough opportunities for professionals to explore different opinions.
  • Caring for a premature baby can be very difficult for parents and families to cope with. If the family is already experiencing problems, and/or if the parents have premature twins/a multiple birth, the risks to the baby/babies may increase.
  • Premature babies may be born with disabilities or chronic health conditions which can be challenging for parents and carers to manage. Children with disabilities are more vulnerable to abuse and neglect.
  • Professionals aren’t always aware of signs that a parent is struggling to meet their premature baby’s needs; for example if parents don’t regularly visit the baby in hospital or bring the baby to medical appointments.
  • Sometimes professionals use generic tools to assess whether a premature baby is thriving, rather than using tools which were specifically designed for premature babies. This can give an unrealistic view of a baby’s progress and may mask areas of concern.
  • There can be a tendency to see the birth of a new baby as an opportunity for a fresh start. Sometimes this may hinder professionals from recognising pre-existing patterns in parents’ behaviour which pose a risk to the baby.
  • Sometimes professionals may be reluctant to raise safeguarding concerns about families who have a new baby because they empathise with the parents and think they are doing their best.
  • Some professionals may underestimate the impact of abuse and neglect on a baby. They may not understand how a child’s experiences during their first few months of life can affect their future development.
  • Sometimes professionals do not understand that levels of abuse and neglect can fluctuate. They may focus on small improvements rather than looking for recurring patterns.
  • It can be challenging for professionals to find a balance between taking the time to build up a trusting relationship with parents and acting quickly to minimise potential harm to a baby. This is particularly the case with pre-birth assessments, when support needs to be put in place before the baby is born.
  • Sometimes professionals are unable to see the parents interacting with their baby – for example if the baby is asleep during visits. This may lead to professionals accepting what parents tell them without evidence.
  • If professionals don’t understand the role of all significant adults in a baby’s life, they may make assumptions about how the baby is being cared for and by whom.
  • Some professionals may prioritise working with one parent, which may mean the other parent isn’t engaged or supported to develop a positive relationship with the baby.
  • If professionals aren’t engaged with all the adults in a baby’s life, they may be less able to identify patterns of behaviour that could pose a risk to the baby’s wellbeing.
  • In cases where parents are separated and there are concerns about the mother’s capacity to care for her baby, the father may be able to provide a safer home environment. Sometimes professionals do not fully investigate this.

Learning for improving practice

  • When carrying out assessments with families who have a baby or very young child:
    • ensure the assessment is child-focused and prioritises the needs of the child;
    • make an objective, evidence-based assessment of parenting capacity and capacity to change;
    • if parents are already receiving support, check whether parents are engaging with the service and changing their behaviour;
    • include an assessment of the parents’ lifestyle and background, and understand the impact of this on the baby;
    • consider all adults who are a part of the baby’s life;
    • assess how the baby interacts with their parents;
    • have a multi-agency approach;
    • consider whether safeguarding action is appropriate;
    • look for and maximise opportunities for early intervention.

  • Assessments should be ongoing so that any new risks to the child can be identified and responded to. Factors which might indicate new risks to an infant include:
    • an increase in substance misuse;
    • incidents of domestic abuse (particularly those which are reported to the police);
    • parents’ mental health worsening;
    • parents’ relationship ending or breaking down;
    • family members mistreating animals;
    • new adults becoming a part of the baby’s life;
    • another pregnancy or a younger sibling being born;
    • moving to a new area.

  • Carry out pre-birth assessments in good time to allow any intervention and further assessment to take place before the baby is born.
  • Have a child-centred approach and focus on the baby’s daily lived experience. If a child can’t talk, indicators of their wellbeing include:
    • their bond with their parents/carers;
    • how they’re dressed;
    • their demeanour and behaviour;
    • where they are positioned (for example, is the parent keeping them close by or are they being left in another room?);
    • the experiences of older siblings and any comments they may make about the way the baby is being cared for.

  • Look beyond a baby’s basic care needs and consider their emotional, psychological and/or therapeutic needs.
  • Consider whether parents need to be supervised when spending time with their baby, for example if one parent has a history of violence.
  • Understand how parents’ behaviour can impact on their baby and know how to discuss concerning or unsafe behaviour with parents.
  • Be curious about parental behaviour and identify any patterns which may pose a risk to the baby.
  • Sensitively explore the reasons behind any specific parenting difficulties which arise as well as suggesting alternative solutions.
  • Check that parents understand and are continuing to follow safety advice and guidance, for example about safe sleeping, bathing or keeping infants away from potential hazards.
  • Anyone working with parents of very young children must be aware of their child protection responsibilities and know how to raise concerns.
  • Children’s services practitioners should always check the parents’ history when working with a family and make contact with adult social care services as appropriate.
  • Professionals should create a multi-disciplinary discharge plan for premature babies who have spent their first weeks in hospital. This should include provision for appropriate support and monitoring the family’s progress.
  • When working with colleagues from different agencies, professionals should use agreed terms with a commonly understood meaning – be aware that some terms have a different meaning in different settings and this can lead to misunderstandings about risk levels.
  • All the professionals who are working with a family should meet regularly without parents present, to discuss any concerns and agree the next steps.

Related learning from case reviews briefings

Parents with a mental health problem: learning from case reviews

Lessons from case reviews published since 2013, where the mental health problems of parents were a key factor.
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Neglect: learning from case reviews

Lessons from case reviews published since 2014, where neglect was a key factor.
Find out more

Returning children home from care: learning from case reviews

Lessons from case reviews published since 2010, which have highlighted lessons for returning children home from care.
Find out more

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