Safeguarding review into Swindon baby Patrick Bradley's death

Patrick Bradley died in hospital in March 2017, four days after killer Paul Rich called 999 to report the three-month-old was unresponsive. Rich admitted squeezing the baby’s ribcage, shaking him and throwing the boy into his Moses basket.

He pleaded guilty to manslaughter and was jailed for seven-and-a-half years at Bristol Crown Court last June.

Now, six months after Rich was sentenced, the authorities have been urged to learn the lessons from baby Patrick’s death.

Serious case review

In a serious case review commissioned by the Swindon Safeguarding Partnership in the wake of the killing, it was said there was a potential weakness in the way information about unborn babies was sought and shared between the NHS, social services and other agencies.

Patrick’s mum, Kirsty Bradley, was accused of misleading health professionals. There was a lack of professional curiosity from some involved in the baby’s care. Concerns were raised about the capacity of the safeguarding midwife, with a six-week delay in her reviewing a referral from Miss Bradley’s midwife.

Liz Murphy, the independent chairman of Swindon Safeguarding Partnership, said: “This is a tragic case and a member of the household has been jailed after admitting to manslaughter. Our thoughts are with those who have been affected by the death of [Patrick].

“The Serious Case Review provided an opportunity to review how agencies worked with a child and their family to identify good practice and any changes that could be made to improve the safeguarding system.

“Partner agencies have agreed to take forward a number of recommendations. These include the correct use by health professionals of terminology so it is clear if a safeguarding referral has been made, to review the arrangements for the sharing of information between agencies on the families of unborn babies and to seek assurance around the capacity of the Safeguarding Midwife.”

The 11-page report details the sad history of the case.

Patrick’s mum was already known to social services in the area where she had been living previously. When she moved to Swindon, the family’s case file was not passed to the borough council despite an attempt to do so by the local authority for the area where she had been living.

Police on Thresher Drive, where baby Patrick had been living with his parents

Miss Bradley was said to have been in a relationship with Paul Rich. Despite him being 25 years older than her, it was said Mr Rich was seen as a “protective factor” and there was nothing to suggest the relevant authorities should be concerned.

When Miss Bradley fell pregnant she mentioned to a midwife that she had suffered mental health issues and a referral was made to the Swindon safeguarding midwife.

She attended an antenatal class with unborn Patrick’s father – not Paul Rich but Gwyn Best. Mr Best was introduced as “a friend”. She only attended one class before texting to say she would not return.

Patrick was born prematurely. He was transferred to the special care baby unit at Great Western Hospital. Staff noted that concerns had been raised during the pregnancy and left a message with social services. That call was not returned. But the community midwife visited the SCBU and told nurses of the family’s history with social services.

While Patrick was a patient at the Swindon hospital, nurses flagged concerns that the parents visited haphazardly and late at night.

Paul Rich visited SCBU and was described as Patrick’s grandfather.

Patrick was discharged from hospital and had lived at home for four weeks before his death.

He was seen by a health visitor at home, a GP and SCBU nurses, none of whom raised concerns about his care.

The serious case review concluded that the professionals involved had followed best practice. But the report’s authors said staff should be alert to the fact family members might not always tell the truth and information about a case should be “triangulated” to give a truer picture.

Read the serious case review.

Reaction from council, hospital and CCG

Responding to the review, Coun Mary Martin, Swindon Borough Council’s cabinet member for children’s services, said: “This is an extremely sad case and our thoughts are with the family of [Patrick].

“This Serious Case Review, commissioned by the Swindon Safeguarding Children Board, has provided a number of recommendations that will be adopted by partner agencies in conjunction with the Swindon Safeguarding Partnership.

“We will continue to monitor the quality of information that gets shared between public sector bodies as we strive to provide the best possible services for vulnerable people in Swindon.”

A spokeswoman for Great Western Hospital NHS Foundation Trust said: “Following the tragic death of Child G there are important lessons for the trust including the significance of clear communication and consistent terminology, both between health and social care professionals, and with parents. This learning has been incorporated into face-to-face training for all maternity staff.

“There is continued learning around professional curiosity so that staff are always asking the right questions and gathering enough information to gain a complete picture of the safeguarding risks for each child and their family.

“A revised online process has now been introduced with social care colleagues, which requires staff to share more comprehensive information on each child and their family as part of any request for information.

“Since this review the Trust has also recruited further support for the safeguarding midwife.”

A spokesman for Swindon Clinical Commissioning Group, the body responsible for NHS services in the town, said: “Although the CCG already has a proactive approach to monitoring the ways in which local healthcare providers comply with their safeguarding responsibilities, this unfortunate case has prompted us to evaluate the processes in place to protect newborn children at GWH.

“Safeguarding leads from the CCG have worked with the team in maternity and neonatal services to review current practices, and to ensure that staff at all levels are not only aware of the warning signs of potential neglect but able to raise their concerns with confidence.

“We will continue to have regular supervision meetings with the named safeguarding team at GWH, while also offering support where appropriate and advising on how existing procedures can be made stronger to protect future patients and families.”

Parents

The authors of the serious case review said efforts had been made to speak to Patrick’s parents. “There has been no response, despite various additional attempts to contact them by letter, telephone and an unannounced home visit,” the report author said.

The parents have since responded to the points raised in the report.

READ MORE: Patrick Bradley's parents hit back at report's findings

The case against Paul Rich

A frustrated Paul Rich hit out at his former partner’s new baby, Bristol Crown Court heard last year.

The 53-year-old was jailed for seven-and-a-half years last June after admitting manslaughter.

Paul Rich

Sentencing him, Mr Justice Soole told Rich: “You were tired after a full day at work and then being up through the night; and you were frustrated that Patrick would not settle.

“At 3.15am you called the emergency services stating: ‘It’s a baby... I’ve just got him out of his cot and he doesn’t look right to me... His eyes are sort of semi-open but he seems all floppy to me.’ The lead paramedic arrived at 3.24am and found Patrick lying on the sofa, unresponsive, pale and blue. It was obvious to the paramedic that Patrick was in cardiac arrest.

“The cause of this, as you finally acknowledged last week, was that you had suddenly assaulted him by compression of the rib cage, gripping and squeezing him from side to side; shaking him; and then throwing him into his Moses basket. You have not given any further detail about the immediate events but, as the Prosecution accepts, this assault was a sudden outburst of frustration with a crying child and must have been over within a very short period of time, perhaps a matter of seconds. However, its consequence was fatal.”

READ MORE: Paul rich is jailed for manslaughter

Defending, Adam Vaitilingam QC said his client had picked up the child, shaken him and thrown him into his basket in a moment of exasperation. “We are dealing with a few seconds of exasperated or frustrated behaviour,” he said.

Rich held down a £35,000-a-year job as a supervisor with Serco and would often look after Patrick despite having worked a full shift. At the time he assaulted the baby, Rich had been awake for around 19 hours.

Following the sentence, Patrick’s mum, Kirsty Bradley, said: “We are absolutely livid that Patrick’s killer is getting such an unduly lenient sentence.”