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Serious Case Review in Respect of Child S (June 2011)EXECUTIVE SUMMARY
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Independent Author Colleen Murphy Completed June 2010
1. Introduction
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.
4.5
Although
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,
in 2008
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.
4.8
Access
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
by
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.
4.12
The
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
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