Review into care of child who almost died due to malnutrition

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 in February 2025.
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.
The Child Saferguarding Practice Review (CSPR) report describe’s the girl’s condition when she was admitted to hospital as: “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 (posterior superior iliac spines).

“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.”

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 report came after a number of missed check ups and GP appointments by the mother both during and after the birth in June 2023, the review found.  The CSPR went on to say how 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 by social services soon after, but it was reported that no action was taken by the service as the mother had consented to work with the family hub. The review established that 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 in the review, but a health visitor in September 2024 noted no significant health or safeguarding concerns.

Following the check up in September 2024, Child K1 was not brought to a physiotherapy appointment and there was no response to the letters sent out, so, as a result, Child K1 was discharged. Health visitors reviewed the records and identified no further health visitor intervention was required.

In mid-December, another anonymous report of concern was sent to the Early Help and Safeguarding Hub (EHASH).

The report read: “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. There was a home visit that followed where the little girl was noted to be ‘under weight, had a nappy rash and long dirty fingernails’.

The report went on to describe how the mother was upset by the referral and refused to engage with social services, not responding to numerous calls between January 7 and January 21, 2025.

After this, a strategy meeting was called by social services to decide whether a formal child protection investigation should be launched (section 47). But the case was closed with no further action as the threshold to progress a section 47 wasn’t met.

Nineteen days after the strategy meeting, Child K1 was admitted to hospital in a critical condition, the CSPR report noted.

The report went into the mother’s background, finding she was still a child (under 18) when she was pregnant and had been the victim of domestic abuse in 2021. Concerns were also raised in respect of potential sexual exploitation, according to the CSPR.

In the initial social services introductory visit, the report found mother’s childhood trauma, mental health and potential learning needs were not explored. 

The review went on to say that services were not ‘sufficiently curious’ to establish who was part of the family network and who was providing Child K1’s care. The report indicated this 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 as well as gaps in information within health assessments led to things about the child’s care being missed, the report added.

The CSPR found: “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.”

The review concluded there was more need for professional curiosity; more supervision should be called for when parents or carers do not engage; more emphasis on gaining historic information about a child’s family was needed; sharing information between services was important; and the need to establish the root cause of faltering growth identified in children. 

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 at hospital. No further information was shared about the little girl’s circumstances or her mother following the admission.