Twin babies case review: Father's attacks preventable
A report on twin babies who suffered serious head injuries in an attack by their father said it could have been prevented and the risk to them spotted before they were born.
A serious case review was carried out after concerns the parents were seen by seven local authority areas both during pregnancy and after the birth.
The twins were admitted to a Somerset hospital after moving from Nottingham.
The father was later jailed while the mother was cleared.
Somerset's Local Safeguarding Children Board (LSCB) carried out the review as the babies, aged six-and-a-half weeks, were living in the county at the time of the attack.History of violence
The family had been in Somerset for just 11 days after moving from Nottingham where the babies were born 10 weeks prematurely.
Nottingham Children's Social Care, housing organisations and health agencies had all been involved during the "pre-birth phase".
The report noted that during their time in Nottingham concerns were expressed by hospital staff about the care of the twins but "the case continued to be assessed as falling below the threshold for child protection".
Both parents had troubled childhoods and the father had a history of violence, the findings said.
The review highlighted many missed opportunities which could have helped to prevent the injuries to the twins.
It said there were "clear signs" that the parents were "struggling to provide the care needed by two vulnerable, premature babies".
It said the "most obvious opportunity" was during the pregnancy in Nottingham when a "comprehensive pre-birth assessment would have revealed family histories" indicating that the parents would need a "great deal of support to care for twins".'Failure to listen'
It said: "The combination of a twin pregnancy, two vulnerable parents, father's history of violence and few support structures should have led to a structured assessment of risk prior to the birth."
The report also highlighted the "second opportunity to prevent the injuries" during "the immediate post-birth period" when both parents were giving "clear signals they were finding it difficult to cope".
The review found that health professionals "failed to really listen to what the parents were saying".
One of the recommendations made is that all the LSCBs involved should look at their pre-birth assessment guidance to "adequately analyse the risk to the unborn child".
The panel asked the Somerset LSCB to contact the government to raise the issue of the rights of unborn children, who "do not have the same right to protection in law as children post-birth".
It said conducting the review had been "extremely complex" as it involved seven local authority areas, 29 individual health agencies, three police forces and seven housing authorities and agencies.