Serious Case Review in Respect of Child S (June 2011)
Independent Author Colleen Murphy
Completed June 2010
1.1 This report summarises the findings from a Serious Case Review that was held in order to consider agency involvement with Child S. Child S died aged 11 years and 9 months. He was found unconscious in a bedroom in the family home at 5.20pm with a lead from a mobile phone wrapped around his neck. Child S was taken to hospital by ambulance and died at 1.20 am the following morning. The post mortem examination concluded the cause of death was asphyxia caused by ligature strangulation; further comment was made that it was unlikely to be accidental bearing in mind that the mobile phone charger was wrapped twice around Child S’s neck. A Police investigation was conducted which identified no suspicion that a third party was involved. A Coroner’s Inquest took place on 29.6.2010 and recorded a verdict of Misadventure with the cause of death as ‘asphyxiation due to ligature strangulation’.
1.2 Child S is the third of six children born to his Mother. Child S had one older full sibling, one older maternal half sibling and three younger maternal half siblings. Child S and his family are of White British ethnicity.
1.3 The father of Child S had an established dependency in alcohol at the time of his birth and there were frequent incidents of domestic abuse in the family home when Child S was young. Child S has not had a childhood relationship with his father. At the time of Child S’s death, he lived with his mother, step father and four of his siblings.
1.4 Child S’s immediate family were known to Children’s Social Care in Leeds throughout his life and prior to his birth. Child S and his siblings were placed on the Child Protection Register for a period of six months when he was two years old. This was related to the behaviour of his father.
1.5 The Review identified long standing concerns indicative of neglect relating to Child S and his three eldest siblings. Concerns about the appearance, demeanour and self esteem of the children were frequently noted by their schools, alongside problems of school attendance. Child S had a Statement of Special Education Needs, and his behaviour proved to be difficult to manage even within a specialist educational setting. Prior to his death, Child S was considered to be beyond the control of the adults around him, and he recklessly placed himself in risky situations.
1.6 This Serious Case Review began in October 2009, and it was conducted in accordance with the Working Together to Safeguard Children guidance issued by the Department for Education and Skills in 2006. The review did however take into account the spirit of the changes contained in the updated guidance issued by the Department for Children, Schools and Families in Working Together to Safeguard Children 2010.
1.7 The complete work and findings of the Serious Case Review Panel is fully detailed in the Overview Report. This document is prepared for public interest, and will be released once the inquest has been concluded and the Serious Case Review has been subjected to evaluation by Ofsted.
2. The Terms of Reference for the Serious Case Review were as follows:
The Terms of Reference for the Serious Case Review are as follows:
· To establish the facts of the case in relation to what was known to each agency in respect of Child S, the parents and siblings within the period between Child S’s birth and the date of his death. (Additional relevant information about the mother and father of Child S outside of this time frame may also be considered);
· To construct a comprehensive chronology of involvement by professional agencies in contact with Child S and the family;
· Briefly summarise decisions reached, the services offered and/or provided to the children and family, and other action taken.
2.2 For each agency to produce an Individual Management Review and address the following key lines of enquiry:
· Did agencies respond appropriately to Child S’s needs, missed appointments and previous instance where he had placed a ligature around his neck?
· Should legal intervention have been considered?
· Was appropriate support in place for the planned transfer from primary to secondary?
· To what extent (if any) might the unavoidable change of Social Worker at the time of the planned move to secondary education, have been a factor in the circumstances of the death?
· To consider lessons learnt from this case in the light of previous Serious Case Reviews undertaken recently in Leeds.
2.3 To sensitively invite family members to contribute to the review process and agree how they should be informed of the progress and outcome of the review;
2.4 An Independent Person to be appointed to complete an Overview Report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action. The Overview Report to address the following key lines of enquiry:
· The services provided to Child S;
· The services provided to all of Child S’s siblings, in so far as they relate to Child S or collective safeguarding information about the family;
· To what extent was the intervention of agencies based on holistic models of assessment?
· Did assessments effectively take account of current and historical information available?
· Was there evidence of timely and appropriate information sharing across agencies?
· To what extent were agencies able to respond to Child S’s distressing behaviours?
· To what extent did agencies identify safeguarding concerns in relation to Child S, in particular in relation to neglect, self harm and suicidal ideation?
· Was risk assessed and reviewed in an appropriate and timely manner?
2.5 To identify any lessons learnt and to confirm how they will be actioned;
2.6 To agree a Media Strategy (in relation to ongoing enquiries) and for publication of the Executive Summary of the Serious Case Review.
3. Membership and Methodology the of Serious Case Review Panel
3.1 The Serious Case Review Panel was comprised of the following people:
· Dorothy Lewis, Independent Chair to the Serious Case Review Panel;
· Head of Service Delivery, Children’s Social Care, Leeds;
· Director of Organisational Improvement, Education Leeds;
· Head of Safeguarding Services, NHS Leeds Trust;
· Detective Chief Inspector, West Yorkshire Police;
· Chief Officer Community Safety;
· Assistant Chief Officer, West Yorkshire Probation;
· Head Teacher, South Area Inclusion Partnership
3.2 The Independent Author of the Overview Report and the Assistant Manager of the Leeds Safeguarding Children Board (LSCB) were in attendance at the Serious Case Review Panel for the majority of meetings.
3.3 The Serious Case Review Panel considered in some detail which family members should be invited to contribute to the review process. The Panel invited contribution from the mother and step father of Child S, an Uncle with whom he was understood to have a close relationship and his eldest sibling who was an adult when the Review was conducted. The Panel was mindful that Child S’s biological father had not had any contact with him for the majority of his life. In these circumstances, the Panel felt it unnecessary to invite his involvement in the review, but the Independent Author did write to him to advise the review was taking place and explain the process.
3.4 The mother and step father of Child S agreed to participate in the review, and they met with the Independent Chair and Independent Author together. Their reflections and comments were helpful in the overall analysis of Child S’s experiences both within his family and in receiving services from agencies.
3.5 Each person invited to contribute to the review will be offered the opportunity of a further meeting to discuss the outcome and findings of the review prior to the publication of the Executive Summary.
3.6 The following agencies contributed Individual Management Reviews to the Serious Case Review:
· Leeds City Council, Children’s Social Care;
· Leeds City Council Environment and Neighbourhood Service;
· Education Leeds;
· NHS Leeds;
· West Yorkshire Police;
· West Yorkshire Probation Trust.
4. Key Issues identified during the Review
4.1 When Child S was born there were a number of indicators present in his family suggestive of a family that was likely to need/require services from agencies to enhance the welfare of the children. The family had a history which included separation, domestic abuse, financial problems and behaviour perceived as anti social by their neighbours. The father’s misuse of alcohol was problematic to the family and the mother required support to act protectively.
4.2 Over the period of Child S’ life, the family presented with classic symptoms of disorganised neglect. The response of agencies was generally insufficiently co-ordinated or focussed with a tendency to focus on quick fix solutions to presenting symptoms rather than through comprehensive assessment to analyse the potential for long term change.
4.3 Each child in the family and referral episode was responded to without taking adequate account of the history of the family and non engagement of the family with agencies or interventions was seen as a reason for closure by additional services such as Child & Adolescent Mental Health Service (CAMHS) and Children’s Social Care, rather than an indicator of increasing concern for Child S in particular but also other children of the family.
4.4 The systematic and enduring nature of neglect requires a consistent inter-agency approach, along with a commonly understood set of indicators and criteria for additional services. This was not evident in the single or multi agency approach to working with Child S or his family. It was evident that on occasions educational establishments recognised the indicators of neglect and had an understanding of the impact on Child S, but appeared ineffective in using this information to enhance Child S’s welfare through their own or interagency services.
there were significant points at which agencies perceived Child S to be at a
higher degree of risk than was recognised by Children’s Social Care (in 2006 a Head Teacher
expressed a view that that Child S should be on the Child Protection Register,
4.6 Children’s Social Care undertook two Core Assessments in 2006 and 2008. Neither assessment was of a good enough standard. They did not collate information from all possible sources about the family (including historical information available to the service) and also failed to analyse this information, to gain an in depth understanding of Child S in the context of his family situation. Important issues such as attachment and the significance of this issue in relation to his presenting behaviour were never considered.
4.7 Child S experienced a high level of exclusion from school in all his education settings. Between the age of 7 and 9 he was excluded 21 times from primary school, and experienced a total of nine additional periods of exclusion from specialist education settings. His school attendance was poor and a reduced half day timetable was used with insufficient attention to the consequences. Child S presented a significant challenge to agencies and education services in particular, put simply, no service appeared to meet his needs.
to tier three and four therapeutic services proved difficult to achieve. In
2006, Child S did not receive a service from CAMHS or the therapeutic social
work team when this was identified as necessary. Once a referral was accepted
4.9 The primary school was able to secure the services of an art therapist speedily in September 2007. Child S initially engaged well with the sessions and the therapist, however, the service continued over an eighteen month period and the focus of the intervention became less evident as Child S’s situation grew increasingly fraught with risk.
4.10 The risks that Child S was exposed to and presented were particularly heightened from late 2006 and the evidence was as follows:
· In November 2006 records state that he tried to strangle his younger sister until she was blue in the face because she would not let him into her room.
· January 2007, Child S had to have 1:1 supervision during any unstructured time at school;
· June 2007, he is recorded as jumping off bridges, cycling dangerously – unsupervised at 9 years old;
· January 2008, an Initial Assessment identified that he was a risk to himself and others;
· In February 2008 his mother found him with a wire round his neck and his head through the gap on the stairs, after he called out to her ‘goodbye mum’;
· His levels of aggression to staff increased in including aggressive behaviour towards teachers, the art therapist and taxi escort;
· September 2008, he was spending time with older boys, drinking, smoking and stealing from shops;
· Observation and concern about his physical presentation;
· January 2009, asking people for cigarettes outside of the shops
· April 2009, he was reported by the art therapist to be speaking in a strange voice that he seemed unaware of;
· June 2009, his mother reported to the Social Worker that he was jumping out of windows late at night;
· By the summer of 2009, large parts of his life were spent unsupervised, and he seemed unable to place any regard to his own safety.
4.11 For Leeds LSCB, a particularly concerning feature of this case is the obvious and ongoing indicators of risk and flaws in multi agency working which were largely unchallenged through the supervisory processes. Over the period of review, ten Social Workers had contact with the family, and, although regular supervision was taking place in the latter years, there is no sense that this was used to review what was known about the family, to analyse the response to need and risk or to question whether there was a consistent framework of multi agency working. Those agencies that worked closest and directly with Child S were particularly concerned for his welfare; however, despite the gravity of his presenting needs no formal challenge was made by anyone, about the appropriateness of the response to his needs. The Review considered that managers with safeguarding responsibilities need to be better equipped to deal with the dilemmas and challenges of working with families, where complex assessments and multi agency risk management is a necessity.
last multi agency meeting that took place with regard to Child S was on
29.4.2009. This meeting was attended by
· his violent outbursts were worse in severity although less frequent;
· he was a loner and more isolated;
· in art therapy he had spoken in a babyish and frantic voice that could not be understood which he did not seem aware of;
· his contacts with family resource worker was fluctuating, he would chose not to attend or create a situation that would be unsafe;
· his presentation was poor not bathing and sleeping in clothes in contract to other siblings;
· he was not available for transition work due to erratic attendance and rejection of what school had to offer;
· his family struggled to engage with support services consistently despite significant resources and intensive work.
· he was increasingly making himself less accessible to school or family and large tracts of his life were spent unsupervised and at the fringes of society with little regard for his own safety.
Despite this alarming picture for a child of 11 years, both agencies agreed that they would be closing the case because of non co-operation by the adults with responsibility for Child S’s welfare. This decision was not focussed on the needs of Child S, did not place sufficient emphasis on the risks he was exposed to, and did not give due consideration to the possibility of legal intervention to promote Child S’s protection and welfare.
4.13 It is not possible to determine what actually happened on the day Child S died. Whether Child S intended to harm or kill himself is difficult to know. However, from an earlier similar incident in February 2008 when he called out goodbye to his mother, it is possible to establish that he understood the potential consequences of a wire wrapped around his neck. The response to the incident by Health and Children’s Social Care was entirely insufficient given that one of the most accurate predictors of suicide is previous attempts. Child S was not assessed by CAMHS until nine months after the incident, and as already stated, he was closed to CAMHS because he was not taken to appointments, although it was considered he still needed the service.
4.14 The Review concluded that Child S was at risk of harm throughout his life. Over time that risk became significant but this was not recognised or responded to in accordance with Section 47 Children Act 1989. The question of whether his death was predictable or preventable is difficult to answer with certainty; the Serious Case Review Panel and the Independent Author shared the opinion that Child S could and should have been better protected by agencies through compliance with expected practice standards in relation to assessment and planning. It is therefore reasonable to conclude that if his needs had been holistically assessed and appropriately responded to an earlier age, the critical pathway of Child S’s life could have been different with a more positive outcome achievable.
5. Identified Learning
The following recommendations are made to support the identified learning from the Serious Case Review:
5.1 Leeds Children’s and Young People Social Care (CYPSC)
· There should be a review of the core assessment record forms to ensure they comply with all the domains in the Assessment Framework;
· There should be a review of training on assessments to ensure that assessment training focuses on the needs of children;
· A new supervision policy and procedure should be written with clear arrangements for contracts; recording and management scrutiny of practice with children and in particular the need to challenge the action of parents;
· CYPSC should commit to the protocols which are being developed respond to situations where services are either not available or there is disagreement between agencies about the need for the service;
· A protocol for agreed action where there is thought to be a risk of self harm or suicide should be developed to respond to all Social Care staff. This should include arrangements for risk assessment;
· A quality assurance process should be established which monitors the incidence and quality of practice of core assessments undertaken and to ensure the needs of each child is analysed within a historical context;
· Social workers should be required to undertake training on working with families where chronic neglect exists.
5.2 Leeds Education Services
· All schools and settings are reminded every year in the summer term about the importance of following the protocol for the hand over of Child Protection records at all key stages and in-year transitions;
· Repeat advice and guidance is issued to schools and settings in regard to appropriate training, supervision and accountability for child protection and children in need monitoring;
· Re-issue advice to schools regarding exclusions that highlights, for identified vulnerable children, the need for the school to convene a multi-agency meeting prior to exclusion so as to ensure the correct support is in place to address the holistic needs of the child and retain them in the mainstream setting with appropriate support;
· Schools are advised on good practice in terms of the efficacy of reduced
timetables to improve attendance and keep children safe and should only be considered in the most exceptional circumstances and they should only ever apply for a fixed period of time;
· Following a review to issue revised guidance and advice to schools and settings on referral mechanisms to specialist and commissioned services;
· Schools and settings to regularly review plans for pupils with SEN, including transition plans and to call interim reviews when it is clear that pupils are at risk of poor outcomes;
· Schools and other provision to clearly identify vulnerable pupils and support them to access summer activities.
5.2 Leeds Council Environment and Neighbourhood Service
· That the relevant Arms Length Management Organisation (ALMO) and Housing Service establish and implement information sharing protocols with CYPSC where vulnerable families are identified. This will allow officers to be alert to specific children who they encounter while following housing management rules.
5.4 NHS Leeds
· That the Head of Service, Health Visiting ensure that guidance is given to health visitors regarding the need to retrieve previous health visiting records when new records are commenced within 3 months of this review;
· That the Head of Service School Nursing review the school nursing care packages which are offered to children and young people to ensure that they are sufficiently robust to address issues of neglect and are appropriately linked to the competencies of the staff who assess and deliver these packages within 6 months of this review;
· That the Head of Service, School Nursing will re-notify all school nursing staff about the correct, up to date procedure to be followed when a child moves to a school with a different allocated team within 1 month of this review;
· That the Head of Service, CAMHS will review the guidance offered to staff about the preparation and circulation of the summary letters which follow consultations subsequent to the initial consultation within 3 months of this review;
· That the Head of Service, CAMHS will review the service information provided to other disciplines and agencies to ensure that it appropriately describes the route to be followed in the case of self harm in children and young people within 3 months of the review.
5.5 West Yorkshire Police
· The West Yorkshire Police will ensure that their policy for attendance at Initial Child Protection Conferences is fully reviewed in accordance with Working Together To Safeguard Children 2010 and that their compliance with policy is subject to regular audit;
· The West Yorkshire Police will ensure that the police action taken when attending at reports of domestic abuse is compliant with the West Yorkshire Police Domestic Abuse Policy and the LSCB Safeguarding Procedures, specifically in relation to physically checking on the welfare of children resident within the household and ensuring that their details are correctly recording on VIVID/Niche database. Compliance with Policy will be measured by regular audit.
5. 6 West Yorkshire Probation Trust
· When an adult is convicted of an offence against an animal, a notification will be made to Children’s Social Care.
5.7 Recommendations arising from the Overview Report
· The Chair of Leeds SCB to ensure that a review is undertaken of interagency protocols/procedures on neglect; that improvements are identified and partner agencies required to ensure compliance of their staff.
· That Leeds Safeguarding Children Board review interagency guidance for resolution of professional difference and to identify any improvements required, then require partner agencies to ensure staff are aware of the guidance and ensure its appropriate use;
· The Chair of Leeds SCB to require partner agencies to review and where necessary develop further their strategies for engagement with hard to reach/help children and young people and parents/carers in order to maximise the accessibility of services to children most in need;
· The Chief Executive, Education Leeds to ensure that restraint policies in Specialist Inclusive Learning Centre’s are reviewed and revised to include the provision of independent advocacy where a complaint is received from a child or parent;
· The Chair of Leeds SCB to require all partner agencies to ensure that the Local Authority Designated Officer (LADO), is consulted in all cases where a complaint or allegation is made about the conduct of a staff member in relation to a child or young person;
· That the Chief Executive, Education Leeds undertakes a review of the role and function of the art therapy service, focussing on the adequacy of governance arrangements and compliance with the duty to safeguard requirements in accordance with section 175 Education Act 2000;
· The Chief Officer CYPSC to ensure that Initial and Core assessments are completed individually for each child within a family;
· The Chair of Leeds SCB to require partner agencies to review, and where appropriate develop their training provision for managers focussing on the assessment and management of risk within case work supervision;
· The Chair of Leeds SCB to require partner agencies to review and where appropriate develop, their training provision focusing on the analysis of ‘risk’ for staff undertaking assessments of children & young people;
· The Chair of Leeds SCB to ensure that audits of cases subject to child protection and children in need processes identify the adequacy of interagency working;
· The Chair of Leeds SCB to ensure the implementation of a protocol to co-ordinate interagency responses to children/young people who self harm / have suicidal ideation;
· The Chair of Leeds SCB to ensure that a training programme is developed and implemented that increases child care practitioners’ awareness of child and adolescent mental health, including self harm and suicide;
· The Chair of Leeds Safeguarding Children Board to ensure that the referral processes between CAMHS and the Therapuetic Social Work Team are reviewed to ensure that there are no delays in allocation of cases to the most appropriate service.
The Serious Case
Review Panel would wish to convey their deep sympathy and condolence