Serious Case Review in Respect of Child J  21.07.09

1.     Agencies Involved

Children and Young People’s Social Care, Leeds City Council
Leeds Health (Leeds Primary Care Trust/Leeds Teaching Hospital Trust)
West Yorkshire Probation Service
West Yorkshire Police
Education Leeds
Leeds Youth Offending Service
Environment and Neighbourhoods (Housing Services), Leeds City Council
Connexions West Yorkshire
Carr Gomm

The Crown Prosecution Service

2.     The Independent Overview Report Author

The Overview report was compiled by Dr. Arnon Bentovim MB BS FRCPCH FRCPsych MInstPsychoanal DPM, Consultant Child & Adolescent Psychiatrist.

Dr. Bentovim has extensive experience in child protection matters, assessments for courts, young people who are sexually abusing, research and training.

3.     Reason for the Report

This report provides a summary of an Overview Report which was commissioned by Leeds Safeguarding Children Board in accordance with The Local Safeguarding Children Boards Regulations 2006 and Working Together to Safeguard Children (TSO 2006). It followed the death of child J. The completed review was accepted by the Board on 22 July 2008.

This summary is based upon information provided, via the Serious Case Overview Review Panel, from Individual Management Reviews carried out by agencies that provided services to child J 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.

4.     Purpose of a Serious Case Review (Working Together 2006 8.3 – 8.4)

The purpose of a Serious Case Review is to:

4.1.  Establish 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;

4.2.  Identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result; and

4.3.  As a consequence, improve inter-agency working and better safeguard and promote the welfare of children and young people.

Serious 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.

5.     Summary of the case and background to the Report

The scope of the review period was determined as being 1985 – 2007 to enable consideration of the childhood experiences of the adults in the life of child J who were comparatively young and had themselves experienced challenging childhoods.

When 17 years of age a prosecution of a charge of rape of a girl under 16 against child J’s paternal uncle was withdrawn due to inconsistencies in the evidence.

There were medical concerns during the mother’s pregnancy with child J’s older sibling and subsequent to the birth the Police were called on a number of occasions to attend incidents of domestic abuse.

Child J received universal services from midwives, heath visitors, GP and Sure Start.

There was no involvement with the family by Children’s Social Services until September 2005, when child J, aged 10 months, was taken to an Accident and Emergency Department by her mother, two days after sustaining a burn to her shin caused by hair straighteners. A multi agency strategy meeting convened by Children’s Social Services considered information about child J, her family and the burn, taking the decision that due to the delay in the parents seeking medical attention, Children’s Social Services should complete a core assessment. That assessment was not completed.

Child J was subsequently discharged from hospital and there followed a significant number of occasions of non attendance for follow up outpatient appointments. The health visitor continued to have intermittent contact as the family then moved homes a couple of times.   Carr Gomm (providing housing support) and Sure Start became involved.

In the months immediately prior to child J’s death the three young adult males (father and two uncles) were supervised by the National Probation Service.

On the day in question child J was put to bed in the early evening.  She was subsequently discovered to be unresponsive and an ambulance was called but she was found to have died. Subsequently child J’s paternal uncle  was found guilty of her rape and murder and sentenced to life imprisonment with a tariff set at 35 years.

6.     Lessons to be learnt

The review has highlighted a number of areas where lessons can be learnt with a view to improving future practice:

6.1  The impact of parents’ own experience of being parented on their ability to care adequately for their children.

All the adults in child J’s life had experienced challenging childhoods. There was no evidence that the impact of this was considered in relation to their capacity to care adequately for child J and her older sibling. Had the core assessment, agreed at the strategy meeting following the burn to child J been completed, it should have included these factors.

6.2  Maintaining the engagement with education of children and young people who exhibit challenging behaviours.

As children, the three adult males had exhibited resistant behaviour in school. All were subject of a number of exclusions and became disengaged with education from their early teens. Attempts were made to refer them for therapeutic and counselling services but these did not materialise. It is concerning that support was not provided consistently to these boys to maintain their participation at school.

6.3  Identification and assessment of persons posing a risk to children and young people:

The withdrawal of the prosecution in 2003 of the paternal uncle for rape following evidential inconsistencies in the Police investigation and the lack of consideration of a lesser charge by the Crown Prosecution Service, resulted in there being no assessment of his behaviour at the time. This impacted on subsequent assessments of risk undertaken by the National Probation Service. Given the later conviction for the rape and murder of child J, it is possible that assessment of any previous sexually abusive behaviour may have identified risk and risk management factors. Identification of the paternal uncle as a person posing a risk to children and young people would have increased the likelihood that this information would be shared on a multi agency basis and the risk to the children in the family being assessed and acted upon.

6.4  Consideration of ‘parenting capacity’ in antenatal assessments of young women aged under 18 years.

Given that the mother was still a child when pregnant with child J’s  sibling, an assessment of her social circumstances and potential to parent may have alerted health services and subsequently other agencies to any concerns. This may have resulted in a multi agency response that considered future risks and measures to manage them.

6.5  Consideration of the impact that domestic violence and adult alcohol / substance misuse can have on children.

Incidents of domestic violence and the alcohol / substance misuse of the three young men were not shared on a multi agency basis, resulting in professionals in different agencies who were involved in the family being unaware of key factors in the children’s lives. An opportunity to collate and assess the significance of these factors was missed when the core assessment on child J was not completed by Children’s Social Services. It is possible that a more comprehensive understanding of the circumstances in which the children were living would have indicated that they may have been suffering, or been at risk of suffering, significant harm and a Child Protection Conference convened. This would have had the added benefit of enabling consideration of up to date medical opinion regarding the burn to child J. Had a decision been made subsequently to place the names of the children on the Child Protection Register, their home and family circumstances would have been subject to multi agency oversight and assessment.

6.6  The impact of any delay in resolving differences of medical opinion in respect of injuries sustained by children and young people:

The decision making at the strategy meeting was influenced by the view of the Police and initial medical opinion that the burn was consistent with explanations given and therefore accidental in nature. The opinion of senior paediatric staff that the burn was more likely than not to be non accidental was not formulated until after the strategy meeting, and although this information was sent to Children’s Social Services, there is no record of its receipt. As a result the strategy meeting was not reconvened to consider this significant factor. Had it been aware of the view that the burn was likely to be non accidental, it is likely that a child protection conference would have been convened, with consequent improved safeguards in place for the children.

6.7  Assessment of risk posed by offenders who are in contact with children and young people.

Assessments undertaken by the National Probation Service in respect of the three young men did not result in enquiries being made about their contact with children being passed on to Children’s Social Services. The potential impact on the children within the family of the links between the three young men and their shared problematic behaviour was not considered.

6.8  Communication and information sharing between agencies:

Individual agencies holding piecemeal information about the circumstances of child J’s home life often made assumptions that other agencies were aware of risk factors. The failure to complete the core assessment and thus to construct a multi agency overview of the situation compromised assessments of risk and contributed to the case being accorded a lower priority than it warranted. An integrated approach to the needs of children and young people living in the context of parental difficulties requires close collaboration between services for adults and children.

6.9  The management of capacity constraints on undertaking assessments.

Opportunities to collate and assess information through the completion of a core assessment on the children were not taken. Children’s Social Services identified the need to prioritise other high risk cases, with capacity constraints as an underlying factor, in the failure to allocate a social worker to complete the core assessment. The decision to close the case and the reason for such a course of action was not considered by a senior manager. It is not possible to say that the tragedy of child J’s death would have been forseen or prevented had the core assessment been completed but it should have highlighted the range of risk factors to which the children were exposed and triggered a multi agency response.

6.10 Interagency assessment and management of risk.

Discussion at the Serious Case Review Overview Panel suggested that with respect to the identification and assessment of risk there was little that was different between this group of young adults and others in the area. However, research on young people growing up in social environments of significant adversity does not indicate uniform outcomes. Professionals need to look at the balance of risk and protective factors in each case. Careful assessment of the full circumstances of the children’s lives should have indicated that they were exposed to significant risk. The Overview Report indicates that there were areas of risk which were not fully integrated, leading to a lack of action that could have taken place which may have prevented the death of child J.

7      Recommendations

The recommendations have been drafted with a view to being SMART (specific, measurable, achievable, realistic and timely).

Environment and Neighbourhoods (Housing Services)

1.       The Chief Officer will ensure that all relevant Environment and Neighbourhoods staff undertake child protection awareness training.

Leeds PCT & Teaching Hospitals Trust

2.       The Chief Executive of the Leeds Teaching Hospital Trust will ensure that all telephone calls and conversations regarding a child’s care should be recorded in appropriate records.

3.       The Chief Executive of the Leeds Teaching Hospital Trust will ensure that a written process is in place to manage differences of medical opinion that have resulted from the undertaking of child protection medicals. 

4.       The Named Doctor for the Teaching Hospital Trust will ensure that where there is a change to a previously expressed opinion regarding a child protection medical this must be communicated in writing to the chair of the strategy meeting with a request for a written acknowledgement.

5.       The Named Doctor for the Teaching Hospital Trust will ensure that current plans are progressed to identify a lead paediatrician to co-ordinate assessments in all cases of suspected child abuse. 

6.       The Head of Midwifery (Leeds Teaching Hospital Trust) will review the antenatal risk assessment tool to ensure that social circumstances and parenting capacity issues are addressed in relation to young women under 18 years of age.           

Leeds City Council C&YP’s Social Care

7.       The Chief Officer Children’s Social Care will ensure Social Care managers chairing strategy meetings take responsibility for identifying a minute taker and signing off minutes which include action points, timescales, agreed roles and responsibilities and an agreed mechanism for reviewing completion of the action points (including reconvening if further significant information emerges).

8.       The Chairs of strategy meetings will ensure that written action points are circulated to all parties within one working day.

9.       The Chief Officer Children’s Social Care will ensure arrangements are in place for strategy meeting minutes to be circulated to all parties within ten working days.

10.      The Chief Officer Children’s Social Care will ensure that Team Managers always nominate one worker to be responsible for recording information when more than one social worker is involved in a child protection investigation.

11.      The Chief Officer Children’s Social Care will ensure that all assessments must be completed prior to case closure. Where capacity issues prevent allocation and/or completion, team managers should notify Service Delivery Managers, who should make alternative arrangements for outstanding work to be completed.

12.      The Chief Officer Children & Young People’s Social Care will ensure that notifications from the Police of domestic violence incidents in families where there are C&YP are monitored and that repeat notifications trigger analysis and appropriate referral.

13.      The Chief Officer Children’s Social Care will ensure that core assessments include all the relevant domains of the Assessment Framework, including the family history and functioning, parents/carers’ own experience of being parented and, where relevant, the parenting capacity of extended family members who are involved in supporting a family.

West Yorkshire Police

14.      The Chief Constable will ensure that all children and young people who are victims of alleged sexual abuse are notified, and where appropriate referred, to Children & Young People’s Social Care.

15.      The Chief Constable will ensure that West Yorkshire Police, in conjunction with Children & Young People’s Social Care, develop a threshold based referral process for domestic violence cases involving families with children.

16.      The Chief Constable will ensure that West Yorkshire Police Child & Public Protection Unit reviews supervisory arrangements and introduces minimum standards in relation to the direction, regular review and finalisation of all active child protection investigations.

17.      The Chief Constable will ensure that all non-familial child rape investigations are managed under the direction of an appointed Senior Investigating Officer.

National Probation Service - West Yorkshire

18.      The Chief Probation Officer NPS-WY will ensure that Offender Managers notify Children’s Social Care in writing where an offender is subject to statutory supervision, having been convicted of violent and/or sexual offences resides, or has contact, with children.

19.      The Chief Probation Officer NPS –WY will ensure, in conjunction with the Chief Officer Children & Young People’s Social Care, that current arrangements for notification are reviewed and a protocol agreed.

20.      The Director of Offender Management NPS-WY will ensure that Risk Management Plans are implemented by Offender Managers and that reasons for non implementation are recorded.

21.      The Director of Offender Management NPS-WY will ensure that the accuracy of OASys basic information is checked and that all details have been taken into account when undertaking risk assessments.

22.      The Directors of Offender Management and Interventions will undertake a review of the way ‘Enforcement’ and ‘Enforcement Letter’ protocols operate between Offender Management and Interventions sections at the office concerned.

23.      The Chief Probation Officer NSP-WP will write to the National OASys Review Group identifying concerns that the OASys system can underplay the significance of  drug misuse as it relates to offending.

 Education Leeds

24.      The Chief Executive Education Leeds will ensure that the content of training is reviewed; take up of training for school staff monitored and appropriate strategies implemented regarding identification of indicators of persistent conduct disorders in children.

Carr-Gomm

25.      The Director of Operations will ensure that information about risk and needs is received from referring agencies about families with children prior to a service being delivered.

26.      The Director of Operations will ensure that the identity and role of all adults, either living in a household or having significant contact with children and young people, is established and where appropriate, risk assessments undertaken.

The Crown Prosecution Service

27.      The Chief Crown Prosecutor will ensure that all prosecutors are aware of policy bulletin 40, issued in 2007, on how to approach a situation where a complainant aged under 16 in a non consensual sex case cannot, due to credibility or other problems be relied on as a prosecution witness, but there is evidence which points to a lesser, consensual offence where consent is irrelevant (either USI under the Sexual Offences Act 1956 or, post 1 May 2004, a child sex offence contrary to S5 to S13 of the sexual Offences Act 2003, where consent is irrelevant).

LSCB

28.      The Chair of LSCB will ensure that work is progressed via the LSCB Business Plan with both Children’s and Adult services to develop a protocol and provide appropriate training to improve inter agency communication and intervention with respect to children living in the context of parental substance misuse and domestic violence.