#childsafety | How system failed tragic baby hurled at ceiling by his abusive dad

A series of failings have been identified after a premature baby suffered head injuries at the hands of his dad.

Connor Qualter was jailed for 12 months in 2018 after injuring the baby on December 23, 2016.

The baby, who will now be almost four, suffered a catastrophic brain injury as a result of being thrown into the air and possibly hitting its head on the ceiling.

The incident was witnessed by another child, which led to Qualter being convicted of grievous bodily harm. Read more here.

A serious case review was launched by the Hull Safeguarding Children Board to find out why the child was allowed to go home with his mum, just 17 at the time, and Qualter who suffers from ADHD and was using cannabis.

Major shortcomings

The review has revealed a number of alarming shortcomings in the care of the baby including friction between social workers and nursing staff, a failure to find out more about dad’s background and no regular review on the care plans put in place.

The baby, referred to as ‘Baby B’, in the review, was born prematurely at 28 weeks.

Due to the medical complications associated with prematurity, Baby B remained in a hospital neonatal intensive care unit for 14 weeks prior to being discharged into the care of the parents.

Baby B was the first child born to the mother, referred to as MB, who was only 17 at the time, and second child of Qualter, then 20.

While in the care of the neonatal intensive care unit a referral was made to children’s social care for an assessment which led to Baby B being identified as a child in need.

The concerns included the relationship between the parents, their ability to parent safely due to low level maturity and issues around FB’s use of cannabis and his antisocial behaviour.

Approximately three weeks after Baby B’s discharge from hospital, MB made a 999 call and Baby B was taken by ambulance to hospital from their east Hull home.

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Upon examination, it was discovered Baby B had suffered a significant head injury which resulted in acute haemorrhages to both sides of his brain.

In addition to the head injury, Baby B had two marks to the body, one to the hand and one to the leg which were believed to be consistent with bite marks.

MB fell pregnant in March 2016 but their relationship was unstable and Qualter, referred to as FB in the review, was smoking weed.

Premature birth

It soon became apparent MB was likely to have a premature birth and Baby B was born by caesarean at just 28 weeks.

MB was interviewed as part of the review alongside her mum and expressed her shock at what happened and admitted she was unable to stand up to Qualter.

The report says: “MB recalled her relationship with FB had been tempestuous but that they had got along much better after the birth of Baby B.

“MB stated that she had to mother FB as well as Baby B, and was always worried that Baby B would be taken from her because of something that FB was doing.

“MB recalled that she was confused as to why FB was not permitted to visit the hospital but seen as safe enough to live with Baby B.”

Mum struggled to cope

The young mum now believes social services should have acted more decisively.

The review says: “MB said that looking back, she now believes that social workers should have taken more control.

“MB said that young mothers, inexperienced in relationships and experiencing abuse, sometimes need professionals to take charge.

“She said she would always have chosen Baby B over FB, but once the professionals said it would be okay for them to live with FB she was reassured that the professionals thought this was okay.

JAILED: Connor Qualter, who caused severe brain damage to a baby by throwing him in the air and catching him by his arm
JAILED: Connor Qualter, who caused severe brain damage to a baby by throwing him in the air and catching him by his arm

“In wanting a nice family unit, MB admitted she had allowed herself to be too optimistic.

“MB stressed that in her wildest dreams she never thought that FB would physically harm their baby.”

After the birth, staff at the Women’s and Children’s Hospital in Hull found MB and Qualter continually erratic and difficult to manage.

Misbehaviour in hospital

The report says: “Hospital security had contacted the police to report the parents had broken vending machines, stolen drinks and the food of other parents visiting sick children.

“Professionals found their attitudes to be frequently challenging and not focused on Baby B’s care needs.

“FB had, for instance, kept asking if he could adjust the oxygen level for Baby B when saturations were high/low despite being informed this was a nursing task.

“MB was more able to listen and learn about Baby B’s care needs and both parents presented as affectionate to their baby.

According to the NHS, symptoms of attention deficit hyperactivity disorder (ADHD) can be spotted in two types of behavioural problems:

  • Inattentiveness
  • Hyperactivity and impulsiveness

Most people with ADHD have problems which fall into these categories – but not always.

Symptoms in children and teenagers are well defined and usually noticed by the age of six, and usually cause problems in a child’s school and home life.

The main signs of inattentiveness are:

  • having a short attention span and being easily distracted
  • making careless mistakes – for example, in schoolwork
  • appearing forgetful or losing things
  • being unable to stick to tasks that are tedious or time-consuming
  • appearing to be unable to listen to or carry out instructions
  • constantly changing activity or task
  • having difficulty organising tasks

The main signs of hyperactivity and impulsiveness are:

  • being unable to sit still, especially in calm or quiet surroundings
  • constantly fidgeting
  • being unable to concentrate on tasks
  • excessive physical movement
  • excessive talking
  • being unable to wait their turn
  • acting without thinking
  • interrupting conversations
  • little or no sense of danger

“On one occasion FB was observed to smell of cannabis and to have slurred speech.”

Children’s social care made the decision to allocate the new parents with a social worker.

The report says: “MB confided in a nurse that she wanted to leave FB because he hits her including when she was pregnant. She showed the nurse bruising.

“MB said that FB was controlling and kept her bank card and did not allow her any money. This information was reported to children’s social care.”

The parents visited Baby B in hospital every day throughout September 2016. But Qualter was banned from visiting the hospital for a few weeks after another incident.

The report says: “At the beginning of October, FB’s presence on the ward was restricted following an altercation with a father of another baby, in which FB was the protagonist.

“The hospital discussed this incident with the social worker and advised they had no option, because of maintaining safety and order in the ward.”

Domestic abuse revealed

Reports of domestic abuse continued on, on one occasion, MB turned up at hospital with bruising to her face and a split lip.

The review found that, while police had raised concerns about the couple with children’s social care, there is no document relating to the outcome.

The midwifery service was also unaware of the domestic abuse incidents and so was not able to identify further vulnerability issues for the baby.

The review also raised concerns that questions were not asked about domestic abuse and the parenting history of Qualter. The review felt the role of the father generally was not considered strongly enough.

One of the biggest concerns raised was the lack of information being shared among different agencies.

The review says: “Clearly a range of risk factors were evident across the safeguarding partnership but not shared in a way that supported structured consideration of potential risk.

“While no agency failed in any duty of referral, it is also the case that no agency collated information in such a way as to gather information and assess the totality of risk factors.”

Hospital staff concerns

A further referral to children’s social care was made by the hospital with staff raising a number of concerns.

The review said: “The referral to children’s social care was made by the hospital when Baby B was three weeks old.

“The referral outlined concerns about FB and MB’s ability to parent their baby, raising concerns about anti-social behaviour, domestic abuse, and hazardous conduct around medical equipment, FB’s cannabis use and his inability to take direction and advice from nursing staff.

“The referral stressed that Baby B would have on-going complex health needs when discharged from hospital.”

A child in need plan was completed which identified Baby B as “very vulnerable” and would be discharged to MB but Qualter’s parenting would have to be monitored.

Nursing staff frustration

One of the biggest concerns was the friction between children’s social care and the nursing staff at the hospital.

The review says: “The assessment and plan were drawn up solely by children’s social care and, to this end, excluded the necessity for multi-agency working, the extensive experience that other professionals had of the parents and the knowledge about the specific needs of Baby B.

“The plan was not supported by the nursing staff who felt frustrated that they had no forum for debate or disagreement.

“Significantly, the assessment did not source information from the housing provider which would have revealed wider concern about FB’s erratic behaviour from a source outside of the hospital and this would perhaps have challenged the perception that the nursing staff were ‘extremely judgemental’ of MB and FB.”

Concerns over parents dismissed

The review questions the social worker’s overly positive view of the parents and their situation.

It says: “Children’s social care developed a powerful and dominant narrative which resulted in MB and FB being viewed too simplistically and optimistically as parents who needed ongoing support, as opposed to parents who posed a potential risk of harm to their baby.

“The position taken by children’s social care undermined multi-agency working and effectively dismissed the very real experiences of the hospital staff.”

There was also too much faith placed on MB in her ability to control Qualter.

Connor Qualter
Connor Qualter

The review says: “Undoubtedly the child in need plan placed too great a responsibility on MB to oversee FB’s parenting

“It was questioned as to why it was considered that MB could exert a degree of control over FB, in particular when she had disclosed that he controlled her access to money and had locked her in the home.”

Another disturbing find was the idea that the domestic abuse within the relationship was classed as “petty bickering”.

The review says: “In reality, the relationship between MB and FB was very fragile, and there was clear evidence of this impacting on MB’s emotional welfare.

“This was particularly significant as, not only was she identified as the capable parent, but was also expected, within the child in need plan, to oversee FB’s contact with Baby B despite stating that she ‘did not feel confident in tackling FB regarding issues’.”

The review was also critical of the plan to discharge Baby B from hospital.

It says: “The plan for discharge in no way addressed the level of risk. Baby B was a vulnerable premature baby who needed high level care and patient parenting.

“The circumstances of the family included a father with non-medicated ADHD, the presence of substance misuse and domestic abuse and untested parenting outside of the structure of a highly organised hospital environment.”

Behaviour concerns ignored

The review says that speaking to the likes of the police and the housing provider would have revealed more about the situation.

It says: “Consultation with the police or housing provider would have revealed several incidents of erratic anti-social behaviour including a fascination for making fires in the garden area which would have led to deeper consideration about the stability of FB.”

The review found the child in need plan had not been followed and no agencies challenged the support and care provided to Baby B.

A series of recommendations were made to ensure improvements are made to avoid another incident like tragic Baby B’s.

This comes after an Ofsted inspection in January 2019 judged the overall effectiveness of children’s social care services as inadequate.

They found “widespread and serious failures in the recognition of risk and in the quality of social work practice for children in need of help and protection” while “risk and need are not identified quickly enough for too many children”.

As a result of the inspection and the serious case review, during the period February to September this year, the service initiated a review considering all Child in Need plans in place for nine months or over.

Lessons learned

The service is embarking on a mandatory comprehensive learning and development programme for all front line staff and managers.

In addition Hull City Council has commissioned a three-year Signs of Safety programme to deliver multi-agency training which will start in October.

Additional training has now been given to practice supervisors to ensure all relevant information is accessed.

Chairman of the Hull Safeguarding Children Board Darren Downs said: “While these injuries to Baby B were not fatal, they were life changing for the child and on behalf of the whole safeguarding partnership I extend my deepest sympathy to all those affected by Baby B’s injuries.

“The review identifies a number of lessons regarding social work practice and management, which have also been highlighted in the Ofsted inspection, and these lessons have now been prioritised within the wider improvement plan for children’s services.”

Chief Superintendent Darren Downs

Chf Supt Downs says the issues that arose from the review are now being put in place to improve the service.

He said: “The review specifically identified weaknesses in multi-agency practice for reviewing a child in need, how organisations challenge each other in the best interests of a child, as well as being clear that all professionals need to be particularly attuned to domestic abuse in children’s plans.

“The wider children’s services improvement plan includes the commissioning of a three-year Signs of Safety programme to deliver multi-agency training which is due to commence in October this year.

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“Additional multi-agency learning events are also taking place focusing on this, and other, serious case reviews.

“All those involved in the review cooperated fully to consider how agencies work together and to ensure that the lessons learnt will help keep children safe.

“Anyone who is worried about the welfare of a child or young person can share the information confidentially via www.hull.gov.uk/worried or 01482 300 300, or through www.nspcc.org.uk or 0808 800 5000.”




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