Leeds (Schools and Services)
- NHS Direct Yorkshire and
- West Yorkshire Police
- Leeds Children and Young
People’s Social Care
- NHS Leeds
- Yorkshire Ambulance
Service NHS Trust
2.1 Both the Chair of the
Overview Panel and the Overview Report Author were totally
independent of any of the agencies involved in the case. The Overview
report was compiled by Dr Sue Smith PhD., MA., RHV., RGN., BA. Dr
Smith is a senior academic with extensive NHS experience in the area
of Safeguarding Children.
2.2 The Overview Panel
included senior representatives from the above agencies, none of whom
had any direct involvement with the family or any responsibility for
any of the professionals directly involved with the family.
2.3 Contact was made
with Child R’s mother inviting her to contribute to the review.
However, she made it clear that she wanted no involvement.
for the report
Serious Case Review was commissioned in accordance with regulation
5(2) (a) & (b)(ii) of The Local Safeguarding Children Boards
Regulations 2006 which came into effect on 1 April, 2006. Guidance
issued in Chapter 8 of ‘Working Together to Safeguard
Children’ (HM Government 2006) has been followed. It
followed the death of Child R. The completed review was accepted by
the Board on 29 September 2009.
3.2 This summary is based
upon information provided, via the Serious Case Overview Panel from
Individual Management Reviews carried out by agencies that provided
services to Child R and her family. Any opinions expressed are based
on the information available. Any conclusions and recommendations
are based on analysis of the information provided, with the benefit
of hindsight. They are intended to assist in the application of
‘best practices’ for the future and should not be
considered as a judicial opinion based on the rigorous level of
investigation required in the Civil Courts.
of a Serious Case Review (Working
Together 2006 8.3 – 8.4)
The purpose of a Serious
Case Review is to:
whether there are lessons to be learnt from the case about the way in
which local professionals and organisations work together to
safeguard and promote the welfare of children and young people;
clearly what those lessons are, how they will be acted on, and what
is expected to change as a result; and
a consequence, improve inter-agency working and better safeguard and
promote the welfare of children and young people.
Case Reviews are not enquiries into how a child died or who is
culpable. That is a matter for Coroners and criminal courts,
respectively, to determine as appropriate.
of the case and background to the report
5.1 The period to be
covered by the Serious Case Review is from date of Child R’s
birth in 1994 to date of her death in 2008.
5.2 Child R’s
mother was only 14 years when she conceived Child R. When Child R was
born it became apparent within a few months that she had multiple
disabilities including blindness, developmental delay, and epilepsy.
The mother managed the care of her child but sometimes struggled to
attend all appointments with the multitude of health professionals
involved in her care.
5.3 In Child R’s
early years, the family received good support from specialist
educational provision and from practical help via social services
departments. It is not clear how much support her mother received
from her extended family or from her partner and there were times,
especially when later children were born, when she expressed the need
for support. When this was offered on occasions however, she would
change her mind and decline extra support.
5.4 Child R was always
‘visible’ to services and her mother would often contact
professionals herself. On occasions professionals would challenge
her about her administration of R’s epilepsy medication or
about her diet and nutrition. This would sometimes result in very
difficult consultations with professionals which was to have an
impact on later interactions between the family and professionals.
There were times however, when her mother herself raised concerns
about her child but health professionals in particular did not take
the opportunity to intervene in a proactive manner.
5.5 Children and Young
People’s Social Care (CYPSC) became involved with the family
following self referral from the mother in 2004 and following an
anonymous referral about Child R’s sibling in 2005. Assessments
did not indicate the need for child protection procedures to be put
in place. However, on occasions CYPSC continued to provide the mother
with support. CYPSC completed two core assessments and closed the
case, appropriately on both occasions. Professionals’ meetings
and assessments never indicated the need for formal child protection
proceedings to be initiated. However, concerns about Child R’s
diet and weight continued to be a feature of professionals’
5.6 In August 2008 Child
R became ill with chicken pox. She later developed a chest infection
and after calling the out of hours GP service, she was taken to the
local Accident and Emergency (A&E) department where she was
diagnosed with a chest infection, prescribed anti-biotics and
discharged home. Three days later Child R was admitted to A&E via
emergency ambulance. The following day she suffered cardiopulmonary
arrest and died. She was 8 days short of her 14th birthday. There was no post mortem.
5.7 Agencies have since
raised no safeguarding children concerns in respect of the mother’s
5.8 Child R died from
Chicken Pox Pneumonitis, a rare but well recognised complication of a
common childhood illness that has a high mortality and which can
afflict otherwise healthy children. In the absence of a post mortem
examination of the degree to which her poor nutritional state
contributed to the likelihood of her death from this condition is
impossible to quantify. It is therefore, impossible to say whether or
not Child R’s death would have been prevented had professionals
involved in her care and education throughout her lifetime, acted any
6. Lessons to be
6.1 This Serious Case
Review highlights areas of good practice but also areas of practice
which could have been improved in the following areas:
- Assessment, levels of
concern and decision making
- Sharing of assessments,
planning and co-ordination
- Capturing and sharing of
knowledge and information
- Compliance with guidance
6.2 Of particular note is
the finding that a lack of ecological planning and coordination from
all agencies resulted in numerous missed opportunities to provide
support and intervention to meet the very basic needs of a disabled
child; needs which were over shadowed on occasions by the
relationship and lack of trust often apparent between the child’s
mother and professionals.
6.3 However, there is
nothing in this report that indicates an occasion where a child
protection plan would have made more of a difference than provision
afforded to any child in need as identified by the Children Act 1989.
Provision under the law was already in place to override the
mother’s refusal to consent to hospital admission for further
investigations, but this was not considered which may have reflected
the professional level of concern. This was clearly not sufficiently
high for professionals to proactively take the opportunity to admit
Child R for further investigations when the mother herself was
6.4 The ability for
professionals, from health services in particular, to adequately
assess and communicate with each other and other agencies, was
confounded by the sheer unnecessary complexity that was a feature of
the organisational provision for children with disabilities, coupled
with the labile assessment and agreement of the level of concern
among individual professionals
LSCB Independent Chair should ensure that, within six to nine
months, a rolling programme of training which specifically
addresses the need for assessments to be fully ecological, will be
in place for all professionals working with families. This may be
incorporated within existing provision.
LSCB Independent Chair should ensure provision, within twelve
months, of multi agency specialist training to all professionals in
how to handle confrontational parental behaviour or parents who are
difficult to engage, whilst effectively intervening in the best
interests of the child. This may be incorporated within existing
LSCB Independent Chair should, within twelve months, instigate a
review of multi agency training and procedural guidance to ensure
they emphasise the importance of including relevant men as part of
an ecological assessment.
LSCB Independent Chair should, within six months, instigate a multi
agency audit of good practice in seeking the wishes and feelings of
children with disabilities resulting in a package of up to date,
well informed professional guidance, procedures and training within
twelve months of the audit.
LSCB Independent Chair should, within six months, ensure that a
multi-agency audit of record keeping and information sharing is
undertaken, the results of which will inform multi agency good
practice guidance and training.
LSCB Independent Chair should, within twelve months, consider the
means by which professional assessment and decision making is
quality assured with consideration given to the effectiveness of
current systems and the commitment given to supervision within the
LSCB Independent Chair should, within six months, consider the need
for the review and clarification of procedures with regard to
disabled children, with specific reference to thresholds for
referral to CYPSC, and assessment by other professionals prior to
referral to CYPSC .
LSCB Independent Chair will ensure, with immediate effect, that
partner agencies are reminded of the requirement to note in the
chronology each occasion when the child / young person was seen and
to provide information about their wishes and feelings.
Chief Executives/Officers within Education and NHS Hospital and
Community Healthcare Trusts should, within six months, work
together in developing agency protocols that address how the needs
of children with disabilities are assessed and met on the rare
occasions when the children do not attend.
Chief Executives of the NHS Hospital Trust should, within six
months, review and amend accordingly, guidance concerning
documenting in professional records the rationale underpinning
decision making with respect to requesting post mortem examination.
This should be followed by thorough dissemination and training to
all relevant health staff.
Executives within NHS Hospital and Community Healthcare Trusts
should, with immediate effect, ensure that the correct procedures
for making a referral to CYPSC are emphasised in training for
medical staff of all levels of seniority
Executives within NHS Hospital and Community Healthcare Trusts
should, within six months, review current procedures regarding
legal intervention in the best interest of the child when faced
with refusal of parental consent and raise staff awareness
throughout their respective organisations.