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Category Archives: serious case review

What it feels like

I thought that this was a really excellent piece in Community Care and wanted to share it with my readers  (there’s probably some overlap between people who read this and read Community Care, but not total overlap)

http://www.communitycare.co.uk/2013/11/27/feels-like-child-social-work-teams-caseload-dies/

It is something that we try not to think about, but the potential is there with every phone call, every email, every decision you make, the question you ask or forget to ask.

I know that some of my readers think that all social workers are heartless nazi-fascists  –  too certain, coy and hard to please, who need to be lined up and shot come the Revolution *, and I don’t expect to ever change their mind. We will continue to Agree to Disagree.

Nor do I happen to think that social workers are all harp-playing bewinged ministering angels who descend when fear and anguish wring the brow. 

Like any profession, there are good ones and bad ones  (teachers, doctors, lawyers, pop stars). Everyone will have and is entitled to have their own view on what proportion of good and bad makes up the profession.  

 It happens to be a profession where a bad one can cause a lot of misery, but it is also a profession where those within it have to carry a lot of fear and disquiet about making wrong decisions  (either way – the Always/Never myth is, as I and others have discussed, a myth.  http://suesspiciousminds.com/2013/09/29/alwaysnever/ 

Nobody can get every decision right, every time).  

If we as a society constantly ramp up the pressure and consequences of getting a decision wrong in only one direction (always) we do run the risk of getting too many wrong the other, less criticised way (never) 

 

 

*I’m reminded of the phone call I used to get at 9.15am every Monday without fail in an early job, from a man who would tell me that “come the Revolution, you and people like you will be first up against the wall and shot… no offence to you mate”

Yet more Serious Case Reviews

 

Whatever the collective noun for Serious Case Reviews is  (a flurry, a murmuring, an avalanche, a papering, an omphaloskepsis*, a whitewashing?) that’s what we’ve had over the last few weeks.

 

The first I read about this week was from Glasgow, and involved a foster carer who was murdered by a young person placed in her care.  The main lesson was to have been cautious about the very good progress this vulnerable and damaged young person was making in the early days of the placement and to have had proper access and regard to the full chronology of his troubled life.

 

http://www.glasgowchildprotection.org.uk/CHttpHandler.ashx?id=17069&p=0

 

 

The second was Child T, a four year old in Haringey. 

 

http://www.haringeylscb.org/child_t__full_serious_case_review_overview_report-2.pdf

 

Now, if there’s anywhere in the country that is nervous about Serious Case Reviews, it would be Haringey. They were the authority in Victoria Climbie and Baby P, and they really don’t want to have a third tragedy.  They were brave to hold this one, since it didn’t automatically meet the criteria and they could have ducked conducting one.

 

In my opinion, they did the right thing in conducting one – I may as well say up front here, that there are real problems with the way they managed the case prior to that decision. (Whilst I think professionals are often harshly blamed after the event for failing to see into the future, this isn’t one of those. Sometimes a cock-up is just a cock-up, and I won’t defend those.  I have to call this one as I see it, and children were harmed here over many months as a result of professional error)

 

The child did not die, fortunately, though on removal in 2011 was found to have fifty bruises on his body. On my count, there were four episodes of bruising. Alarmingly, the last happened AFTER he was seen with 50 bruises, a few days later, whilst the case was being prepared for Court with a plan of him continuing to live at home.

 

 

(A) On Wednesday 30/6/10, at 10:30 pm, Child T was taken to the Accident & Emergency Department (A&E) at North Middlesex Hospital (NMHUT) by his mother and Mr C. He had bruising around the eyes, forehead and nose. Bruising and swelling was said to have become worse during the day. Mr C said that Child T often ran around the house and ‘bangs and hits himself on the wall’ 

 

Child T was three years old at the time. You may, if you are familiar with Baby P, be having shuddering sensations at the suggestion that the child’s bruises were self-inflicted. We have heard that before.

 

It gets worse than that though, because what follows is something that the professionals never had in Baby P – a direct disclosure

 

(B)On 4/7/10 a Polish speaking doctor, PR1, spoke to various family members who were visiting the hospital. He was told, by Child W, that Mr C had hit her so as to cause bruising to her bottom. PR1 spoke to CP2 who subsequently spoke to the Enfield Emergency Duty Team2 (EDT) as it was now the evening. It was agreed that there were no grounds to keep Child W in hospital that night but that the concerns raised should be followed up the next day. The following day, 5/7/10, before any follow-up action was taken, Child T was removed from hospital by his mother and Mr C, without the agreement of medical staff. Over the previous days Mr C had increasingly expressed his annoyance about the child’s prolonged stay in hospital, because, he said,of the disruptive consequences for family life

 

[Note the involvement of Enfield, rather than Haringey – it seems that the hospital were slightly confused about which local authority were responsible, but after that referral the case got properly passed on to Haringey]

 

 

I have to say, as a child protection lawyer advising local authorities, having missed (A) would be quite bad but not dreadful, but having missed (B) would be dreadful.  Having missed (B) against the backdrop of Baby P is, on the face of it, hard to fathom.

 

There were bruises to a young child, unexplained, the sibling was saying that the mother’s boyfriend hit the children, the boyfriend was being annoyed in hospital and the child was removed without the consent of the doctors. That is pure alarm bell territory.

 

(It doesn’t HAVE to equate to removal, but it is certainly something that ought to have made everyone involved very very concerned and vigilant)

 

A strategy meeting took place – the medical opinion was reported to be inconclusive  and the police who attended weren’t aware of a domestic violence callout between mum and Mr C that same day.

 

[This is what was actually said, and anyone who thinks that this is ‘inconclusive’ is on another bloody planet

 

The medical report considered at the Strategy Meeting had stated that “I am very uncomfortable with the injury on his forehead. I do not accept that a 3 year old child would bang his head with such severity and not cry out. In addition, bruising on the leftside is in a very unusual place and this cannot be incurred either from fallingor from play. I cannot exclude the possibility that some of these may have arisen from pressure from fingers”  ]

 

 

Despite the strat meeting having concluded and the case progressing to relatively low action on the basis of the social worker and police deciding that the medical opinion was “inconclusive”, the Consultant Paediatrician who first saw the child (CP1) wrote a letter containing this

 

(C) “I would like to highlight that this child had an injury to his forehead resulting in a haematoma… that could only have occurred if there were a large amount of force on impact … the second fact that concerns me greatly is the presence of bruising on the left side of the rib cage. This is an unusual place for bruising to be found in a child and implies a second mechanism of injury taking place, once again for which the parents claim to have no knowledge. My concerns here are that this is a 3 year old boy who has had two separate injuries for which there have been no explanations and each injury individually is concerning and in an area which is quite uncommon in a child of this age”

 

 

I’ve defended social workers before, and I will again, and I defended particularly the social workers in Haringey who worked Baby P because I think that they were fundamentally let down by a paediatrician who didn’t give them the medical evidence they would have needed to act and get the case before a Court.  The paediatricians here did their job properly and they simply weren’t listened to.

 

But I am afraid that this is a smoking gun. If that came across my desk, we would be having an amazingly urgent legal planning meeting (i.e, “I’m on my way to you, RIGHT NOW”)  to discuss this child and work out what we would be doing to keep the child and siblings safe.  If the conclusion was to work with the family to keep the child at home, I’m fairly sure we would have been getting the case before the Court to endorse that plan. I don’t think I’ve ever worked with any local authority lawyer whose advice would not have been “this is going before a Court, as soon as possible”

 

 

(D) On 9th August 2010, Mr C presented at his GP with self-inflicted cuts to his arms. The GP did not make any referral to social services.

 

(E) On 30th August 2010, the mother was seen at an obstetrics appointment with bruising on her arms – the notes showed up the suspicions of domestic violence, the obstetrician invited mother to be admitted overnight, mother declined. She was very nervous and keen to leave, and Mr C was very keen to get out of the hospital. No referral was made.

 

 

(F) On 31/8/10 Mr C took Child T to the GP, saying that he was concerned that he child bruised easily. He had bruises to his back and legs. The GP (GP1) arranged blood tests which indicated no medical explanation for the bruising. On 17/9/10 Child T was seen by a nurse (PN1) for immunisations. She noticed bruises on his arms, legs and back and asked a GP (GP2) to see

him. GP2 examined the child and arranged for him to be seen for follow-up on 22/9/10.

 

 

Now, I already thought that (B) and (C) were bad things to miss, but to add (F) into the equation just reinforces this.  Very often with Serious Case Reviews there’s a prediction bias and hindsight bias that means that working back from a known outcome, we tend to see all the footprints leading up to that event as being obvious and inexorable and that ‘of course that’s where this is all going, how could nobody see it’

 

But regardless of that, which is something to always be very cautious about; if you have suspicious bruises to a child, a strong paediatric opinion about those bruises and then another episode of bruising two months later; something needs to be happening.

 

A worker could, potentially, have gripped the case and made a decision that this risk could be safely managed at home; but that needs to be a conscious and deliberate and deliberated decision, not just inactivity resulting in that happening.  It is STAGGERING that the social worker on the ground didn’t ever share the paediatrician’s letter at (C) with his/her manager.

 

(G) On 14th September 2010, Mr C told his GP that he was injecting heroin every day. Three weeks later, he said he was drug-free and needed no further help.

 

(H) When the sibling child Y was born in December 2010, hospital staff noted tension and arguments between the mother and Mr C

(I) On 15th  February 2011, the case was closed by the social worker

 

(J)  Three days later, on 18/2/11 (a Friday) police were called to the family homeby Ms B who made allegations of violent conduct by Mr C to her and to Child T. Police could see that the child was extensively bruised and they arrested Mr C. Child T was left overnight with his mother. There was no recorded consultation with the EDT at that point

 

(K)The following day Child T was taken by police for medical examination and was seen by a paediatric registrar (PR2). The EDT had been made aware of the situation in the morning and both police officers and an EDT officer, EDT1, attended the medical. Child T was found to have more than 50 bruises of varying ages and sizes. He told the doctor of having been hit with a belt and a

stick by Mr C. The doctor judged that many of the injuries were caused by physical abuse and that others were ‘highly suspicious’

 

(L) The doctor spoke to Ms B who described how she had been the subject of repeated physical assaults by Mr C. She also said that she had suspected that Child T was being abused by Mr C and that Child T had told her this. She further said that Child W had now also spoken of being physically assaulted by Mr C and that he had tried to drown her whilst bathing her a few weeks previously. She said she had not told Ms B at the time as Mr C had made her promise not to do so.

 

And this is obviously where proceedings finally began, right?

 

Wrong. Professionals agreed with mum that Mr C would move out, and that the children would stay with her.

 

(M) On 22nd February 2011, the children were all medically examined. The medical opinion was that the three older children had all been physically abused by Mr C, and that mother had failed to protect them and that the children should be removed to a place of safety.

 

As a result of that conclusion, the LA decided that proceedings were inevitable.

 

(N) The next day, (23.02.11) the social workers met with mum and told her that care proceedings were to be initiated. In a police interview at around the same time, Ms B said that she knew that Child T was hit more frequently when Mr C was taking drugs

 

 

(O) A Strategy Meeting was held on 25/2/11. Information had been gathered from the various health services involved and, for the first time, the facts of repeated bruising to Child T were drawn together with the knowledge of the current and previous injuries. Agencies were concerned that Ms B and MGM were aware of the abuse and had not acted to prevent it. It also appeared that there may have been discrepancies in the accounts they had given to various agencies. However there had been no evidence that either of them was responsible for any previous physical abuse and there was no indication that the children might be directly harmed by them, or did not wish to be with them. It was confirmed that care proceedings were to be initiated but that there should be no immediate attempt to remove the children.

 

(P) On 28/2/11 Ms B told SW2 that Child T had new bruising. Ms B claimed that she had asked Child T about this and he had said that the injuries had been inflicted by that social worker, SW2. Later that day Child T was taken to Accident & Emergency, NMUHT, in the company of his mother, a different Social worker and an interpreter. Child T said that the “lady” hit him. When asked what the lady looked like and how she did it, he was unsure. Following a medical examination, where new bruising was confirmed, and some new bruising was seen on Child W, all four children were brought into the care of the local authority.

 

 

 

 

On this one, I’m afraid that there is blame – it isn’t just a failure to predict something unpredictable, it isn’t taking an informed decision that the risk was manageable and the outcome turned out bad. This is a basic failure not to recognise what risk looks like and what to do with it.

 

I feel bad for the people involved, and who knows what the workloads and pressures were at the time; but I’m afraid that this is systemic failure, not just making a judgment call that proved wrong after the event.  It is REALLY, really hard to see why that vital letter from the paediatrician at (C) never got escalated into a child protection issue. The social worker never discussed it with her manager, and it did not get escalated into a Legal Planning Meeting.

 

If this is happening at Haringey, which must be alive like no other authority to the perils of getting child protection decisions wrong, something has gone very badly awry – perhaps locally, perhaps nationally.

 

Again, as with Keanu Williams, the case was effectively ring-fenced into a ‘child in need’ case at an early stage, and thoughts about child protection disappeared once the decision was made that this was a “child in need” case.  Even then, things aren’t great – he wasn’t properly treated as a “child in need” with a formal plan and review system. He just got lost.

 

 

I agreed with Eileen Munro that when one looks at Daniel Pelka’s case through the eyes of any individual professional it is hard to say that they got it wrong and that another worker in their shoes would not have acted similarly, but that’s not the case here.

 

In many ways, this Serious Case Review raises more worrying issues than the Baby P one – in that case, the local authority never had in their hands the medical evidence that would have allowed them to save Baby P. Here, the evidence was handed over and simply stuck in a filing cabinet without its significance being absorbed or considered until this child and his siblings sustained many more months of physical abuse.

 

I’m not sure that it gives us ‘lessons to be learned’ in general practice – the individual failings here were so pronounced and obvious that the real lesson is ‘if people don’t do their jobs properly, bad things can happen’.

 

Haringey’s Local Safeguarding board response, in the interests of fairness, is here  – and the incidents were two years ago, so they have had time to make some changes.

 

http://www.haringeylscb.org/haringey_lscb_s_response_to_the_scr_of_child_t-3.pdf

 

(I didn’t think it was great, to be honest, and it was very light on how they would prevent social workers wrongly going down the ‘child in need’ path when child protection is the real issue. Or that a strat meeting could so utterly misunderstand what the medics were saying. But at least there’s now a powerpoint strategy.  )

 

 

 

 

*For those who have made it thus far, Omphaloskepsis is ‘navel-gazing’ – it came into prominence during the Renaissance, when there was much debate about what a painter should do when painting the midriffs of Adam and Eve. Did they have belly buttons, or having never been in the womb, were they smooth?  If God made Man in his own image, does God have a belly button, or not? Because this was such a controversial issue, many such paintings just have hands or branches covering the vital area.

Are we learning anything?

 

A discussion on Serious Case Reviews, Keanu Williams and Professor Ray Jones.

 

Tragically, Serious Case Reviews seem to be piling up at the moment. We have just had Daniel Pelka’s, Keanu Williams’ came out last week. No doubt we will have one soon on Hamza Khan and I have already read today of another mother charged with the death of one child and neglect of another three. As we know from recent articles, most social workers don’t manage to find time to read them, and anyone who does read them finds the same themes continuining to crop up.

                   

The Keanu Williams one is here   http://www.lscbbirmingham.org.uk/images/stories/downloads/executive-summaries/Case_25__Final_Overview_Report_02.10.13.pdf

 

 

{This one actually identifies really early on that Keanu’s death could not have been PREDICTED, but that he ought to have been identified as a child who was at risk of significant harm. We actually know from reading the Serious Case Review that his social worker took the case to Child Protection Conference, with a report identifying why Keanu was at risk of significant harm and why he should be placed on the register and have a child protection plan – the Conference took a different view and decided Keanu was a child in need, instead

 

“A well-argued social work report, stating the risks and concerns that had been assessed for Keanu, formed the basis for the Child Protection Conference. However, the Conference concluded that Keanu did not require a Child Protection Plan but was a Child in Need requiring a family support service such as the nursery place as the focus of the meeting changed.

 

 

The outcome of the Child Protection Conference led to a loss of focus on Keanu, because the Child in need services moved the attention towards practical matters such as the lack of settled accommodation and provision of the nursery place.

 

Paradoxically the services failed to consider precisely what the impact was on Keanu’s development and welfare of being moved around and cared for by many different people.” }

 

But what also interested me was Professor Jones take on Serious Case Reviews, as reported in the Daily Telegraph

 

http://www.telegraph.co.uk/news/uknews/law-and-order/10355475/Theres-no-more-learning-left-to-be-done-says-child-protection-expert-in-wake-of-Hamzah-Khan-death.html

 

 

(A brave thing to say, since the gut instinct when reading “we have no more learning left to be done” is  to retort – then why are these cock-ups continuing to happen?)

 

I can sort of see where Professor Jones is coming from. With every child death of this kind there is a clamour for ‘lessons to be learned’ and ‘we must ensure that no other child has to go through this again’  and of course the media clamour that someone in authority must have bungled and they should be identified and sacked. That’s backed very often by central government (at least some element in David Cameron’s rise to power was on his tough handling of Baby P) and their demand that all Serious Case Reviews should be made available to the media and public.

 

The media of course, take a long and dense document, and strip out the bits that show that “Professionals had X chances to save baby Morris” , because that’s what makes the good story. Never mind that any of those chances would only have been a real chance if (a) the professionals could see into the future or (b) were so risk averse that they were removing children with similar histories left,right and centre, most of whom would have been okay at home. 

I will defend professionals from unfair criticisms that they didn’t accurately predict the unpredictable, but mistakes do get made in child protection and where those mistakes are due to sloppy practice or laziness then those responsible ought to be dealt with. If a child died because professionals didn’t make referrals, or the referrals got ignored or visits weren’t made (or you were a paediatrician that can’t spot a broken back), then yes, those involved ought to be rethinking their career – I just don’t believe that having failed to identify that of your thirty kids with bruises and low-level neglect THIS was the one where it was going to go awfully wrong is that sort of mistake.

 

{On the same basis, given how many times serial killers are described as ‘quiet blokes who wouldn’t harm a fly and was nice to his mum’ we could be cutting down serial killing by imprisoning in advance every person like that… Or blaming the police for every such bloke who goes on to commit murder, on the basis that it was obvious that he would turn into a serial killer one day}

 

 

And of course all of those Serious Case Reviews start with the known fact that the child died, and works backwards from that foundation, which allows them to in part discount the very thing that makes social work hard – the tension between family preservation and child rescue.

 

If the child has died, then we KNOW that the child ought to have been removed from home before then and that the family ought not to have been preserved. So the Serious Case Review can just look for any opportunities professionals had to break up that family unit and rescue the child.

 

Here are the things that a Serious Case Review CAN potentially do

 

(a)  Handwringing  (lessons have to be learned)

(b)  Finger-pointing/witch-hunting

(c)  Identifying whether there were flaws in local procedures, or in following those procedures

(d)  If there have been serious and genuine bad practice or negligence, taking action as a result

(e)  Extracting lessons of general principle to be learned in other cases

 

I think that our current system is pretty good at (a), not bad but not great at (b),  pretty poor at (d), okay at (c)  and it THINKS that it is very good at (e) but actually isn’t.

 

So I agree with Professor Jones that most of the ‘lessons to be learned’ are already well-established and well known. We know in advance that common themes from an investigation into a child death will include

 

(i)            That information held by different agencies was never really shared properly and that had one person known all of it, different decisions could have been made

(ii)          That a rule of optimism was applied

(iii)         That a history of low level neglect or bruising continued over time and nobody took it seriously enough

(iv)         That the voice of the child was overlooked or the child simply wasn’t seen enough

(v)          That too much of professional attention was focussed on the adult

 

 

And that having report after report say that, really doesn’t help.

 

I don’t think that the Keanu Williams one is particularly bad, it is fairly typical of these reports (and is to my mind, a better one than Daniel Pelka’s, for example)

 

So do Serious Case Reviews tell us anything at all? Or are they just handwringing and witch-hunting?

 

[I would disagree with Professor Jones on two categories of inquiries  - I think that the Victoria Climbie inquiry did genuinely tell us new and important things about the dangers of walking on eggshells around respecting differences in culture and losing sight of child protection, and I think that all of the inquiries relating to situations where ‘child rescue’ went too far – Rochdale, Cleveland, Orkney Islands, tell us a great deal of significance about what happens not in an individual case where a judgment call went wrong but when there is a systematic failure to properly balance evidence, risk and the desire to keep families together]

 

 

I would myself like to see Serious Case Reviews focussing on whether what had happened in the case throws up issues of poor practice amongst the professionals involved (not that they failed to predict the future correctly, but whether they weren’t alive to the possibility that their prediction might be wrong) or where local procedures need to be improved, and shy away from the ‘broad lessons to be learned’ unless it is a case like Victoria Climbie which genuinely has something new and important to say.

 

Frankly, the only real way to tell whether it was bad luck or bad social work in a Serious Case Review is to run them blind – the board are given information on two cases with children of similar ages and length of professional involvement. One is the child death in question and one is a child who remains at home unharmed.  If child deaths are caused by bungling professionals missing the obvious, then the Serious Case Review ought to have no problem at all in identifying the bad social work that led up to the child death, without knowing which case is which.

 

The Daniel Pelka serious case review

In case you are not aware, a Serious Case Review is an inquiry conducted after the death of a child known to professionals, headed by an independent chair, with the aim being to look at what happened, whether anything went wrong and whether anything can be learned from the process.

 The Serious Case Review is here http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf

 Most of you will have heard of Daniel Pelka. The Serious Case Review summarises the tragic story like this:-

 2.1 Daniel was murdered by his mother and stepfather in March 2012. For a period of at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister Anna was expected to explain away his injuries as accidental. His mother and stepfather acted together to inflict pain and suffering on him and were convicted of murder in August 2013, both sentenced to 30 years’ imprisonment.

2.2 Daniel’s mother had relationships with 3 different partners whilst living in the UK. All of these relationships involved high consumption of alcohol and domestic abuse. The Police were called to the address on many occasions and in total there were 27 reported incidents of domestic abuse.

2.3 Daniel’s arm was broken at the beginning of 2011 and abuse was suspected but the medical evidence was inconclusive. A social worker carried out an assessment but no continuing need for intervention was identified.

2.4 In September 2011, Daniel commenced school. He spoke very little English and was generally seen as isolated though he was well behaved and joined in activities. As his time in school progressed, he began to present as always being hungry and took food at every opportunity, sometimes scavenging in bins. His mother was spoken to but told staff that he had health problems. As Daniel grew thinner his teachers became increasingly worried and along with the school nurse, help was sought from the GP and the community paediatrician.

2.5 Daniel also came to school with bruises and unexplained marks on him. Whilst these injuries were seen by different school staff members, these were not recorded nor were they linked to Daniel’s concerning behaviours regarding food. No onward referrals were made in respect of these injuries. At times, Daniel’s school attendance was poor and an education welfare officer was involved.

2.6 Daniel was seen in February 2012 by a community paediatrician, but his behaviours regarding food and low weight were linked to a likely medical condition. The potential for emotional abuse or neglect as possible causes was not considered when the circumstances required it. The paediatrician was unaware of the physical injuries that the school had witnessed.

2.7 Three weeks after the paediatric assessment Daniel died following a head injury. He was thin and gaunt. Overall, there had been a rapid deterioration in his circumstances and physical state during the last 6 months of his life.

Whilst one is tempted to cry that this is unique and will never happen again, and that the idea of a child being deliberately starved and this being allowed to happen is a once-in-a-lifetime case, we sadly know that it is not. We all know that it happened in Birmingham just a few years ago, and there’s a criminal trial ongoing on yet another infant that this happened to, right now.

The findings

Daniel’s mother and stepfather set out to deliberately harm him and to mislead and deceive professionals about what they were doing. They also involved Daniel’s sister Anna in their web of lies and primed her to explain his injuries as accidental.

 

 A pattern of domestic abuse and violence, alongside excessive alcohol use by Ms Luczak and her male partners, continued for much of the period of time from November 2006 onwards, and despite interventions by the Police and Children’s Social Care, this pattern of behaviour changed little, with the child protection risks to the children in this volatile household not fully perceived or identified.

 

 Missed opportunities to protect Daniel and potentially uncover the abuse he was suffering occurred:- 

 at the time of his broken arm in January 2011, which was too readily accepted by professionals as accidentally caused,

 when the school began to see a pattern of injuries and marks on Daniel during the four months prior to his death, and these were not acted upon, and

 at the paediatric appointment in February 2012 when Daniel’s weight loss was not recognised, and child abuse was not considered as a likely differential diagnosis for Daniel’s presenting problems.

 

At times, Daniel appeared to have been “invisible” as a needy child against the backdrop of his mother’s controlling behaviour. His poor language skills and isolated situation meant that there was often a lack of a child focus to interventions by professionals.

 

In this case, professionals needed to “think the unthinkable” and to believe and act upon what they saw in front of them, rather than accept parental versions of what was happening at home without robust challenge. Much of the detail which emerged from later witness statements and the criminal trial about the level of abuse which Daniel suffered was completely unknown to the professionals who were in contact with the family at the time.

 

 A number of critical, significant lessons have been identified by this SCR, which are detailed later, and it is now of utmost importance that they are translated into action by front line professionals and adopted for inclusion within relevant child protection processes and systems and as part of the support and supervision that these professionals require in their day to day work with vulnerable children.

(Eileen Munro has made some interesting comments in the media over the last few days about the tendency of Serious Case Reviews and the media to work backwards from the known tragic and awful outcome to then look at things that in the light of that seem obvious indicators that a tragedy was imminent, without necessarily recognising that similar things do happen in families without such awful consequences.  I think her interview is both timely and brave http://communitycare.rbiblogs.co.uk/childrens-services-blog/2013/09/eileen-munro-admits-i-cant-say-i-would-have-done-better-in-protecting-daniel-pelka/ .   The natural human reaction when hearing a story like Daniel’s is that we MUST be able to prevent this sort of thing happening to a child and that if we didn’t then it MUST be due to a professional having screwed up.  Sadly, it’s a bit more complicated than that. What Munro says about bruises here is very important – you can’t reverse-engineer back that each of those bruises ought to have prompted a reaction without considering what the prevalence of bruising is in children generally)

The information from the body of the report about Daniel’s experiences in that home are heart-rending

It is difficult to speculate what sort of feelings and physical effects Daniel experienced in terms of his issues about food – often referred to as his “obsession”. Certainly the eventual post mortem identified that he was very malnourished and had been subject to serious neglectful care. The school were clearly concerned about his weight and how thin he was, his deterioration since starting school, and of his habit of seeking out food at every opportunity, so much so that it was difficult to control. Daniel however never said he was hungry or spoke about his home life. In reality however no professional tried sufficiently hard enough to engage him to enable him to talk about his experiences at home. Additionally at the paediatric appointment three weeks before his death, he did not communicate in any way with the paediatrician. The injuries at the time of his death were evidence of the high level of trauma that Daniel must have suffered in the later stages of his life, and yet he still attended school on occasions and disclosed nothing of concern. Despite arriving at school with facial injuries on at least two, or more likely, three occasions in late 2011/early 2012, no arrangements were made to speak with him directly or formally about these in relation to any child protection concerns. Without proactive or consistent action by any professional to engage with him via an interpreter, then his lack of language and low confidence would likely have made it almost impossible for him to reveal the abuse he was suffering at home, potentially for fear of retribution if he did disclose anything.

 

5.11 Additional information gleaned from the range of evidence which became known to the SCR Panel and was then presented at the criminal proceedings, demonstrated that the children’s experience, especially for the period from autumn 2011 until Daniel’s death in early March 2012, was considerably more traumatic than was known to professionals at the time. From early October 2011 there was evidence that Daniel was on occasions locked in an upstairs “box room” in the house which had no furniture and smelt of urine, but had a damp carpet and floorboards. There was a mattress which was soiled and there was no heater or toys in the room. This was apparently used as a form of punishment which was referred to in text messages between Ms Luczak and Mr Krezolek. Although Daniel was also said to have usually slept with Anna in her room, which was appropriately clean and furnished, it was unclear how often Daniel was made to sleep or stay in the box room. It was later acknowledged by Ms Luczak that it was in this room that Daniel died.

 

5.12 It was evident that Daniel experienced a harsh degree of scapegoating and emotional abuse by Ms Luczak and Mr Krezolek and he was often the sole subject of physical abuse and neglect, which included deliberately depriving him of food, serious physical abuse, feeding him salt and putting him in a cold bath, on one occasion according to Ms Luczak at the time in early February 2012, leaving him temporarily unconscious because he had nearly drowned. There were further disclosures in the court that Mr Krezolek gave out punishments to Daniel which included making him do sit-ups for an hour, or stand in the corner, as well as do squats or running on the spot. What was most concerning was the apparent deliberate way that such punishments were planned in advance. In her statements and in her evidence at the criminal trial, Ms Luczak apportioned responsibility to Mr Krezolek for the abuse and neglect of Daniel saying that if it was found that Daniel had taken other food whilst at school, that Mr Krezolek would not allow him to be fed that evening or that he would be fed salt so as Daniel would vomit up the food that he had taken while at school. This must have been a most terrifying and dreadful ordeal for Daniel to face at the hands of those who should have been caring for him.

 

5.13 It is challenging to describe Daniel as being neglected physically or emotionally, in that this implies some passivity on the part of his abusers. It is apparent that everything done to Daniel was calculated and deliberate, even his non-school attendance. He did not suffer physical neglect in the ordinary use of the term as he went to school clean and well dressed with a packed lunch, albeit a very frugal one. He likely existed in a constant state of stress and anguish as a result of his terrible treatment at the hands of his mother and Mr Krezolek.

The pattern in the case seems to be one of each incident of concern having been treated in isolation, and of no professional collating and gathering the constellation of concerns and recognising that what was going on here was appalling abuse on a systematic level; despite Strategy Meetings and Core Assessments.

Overall, the “rule of optimism” appeared to have prevailed in the professional response to Daniel’s fracture and to his other bruises. This appeared to reflect a “tendency by social workers and health care workers towards rationalisation and under responsiveness in certain situations. In these conditions workers focus on adult’s strengths, rationalise evidence to the contrary and interpret data in the light of this optimistic view”23 . The explanation of the cause of this injury was too readily accepted as accidental and the initial concerns about the injury quickly downgraded – it remained the case that there was delayed presentation of the injury by a day, and that the medical view was that Daniel would have been in considerable pain, and additionally, that based on medical knowledge and research, the most likely cause of an oblique fracture was physical abuse.

 

It appeared that the medical diagnosis or evidence was deferred to as being the most significant to any assessment of whether abuse was a cause or not of the fracture. It was understandable that the medical opinion could not be certain of the causation, and once there was the comment from the doctor that the mother’s explanation could be plausible, this appeared to quickly reduce concerns and actions by the Police and CLYP. In fact there were some inconsistencies in the explanations given. What was missing from the Strategy Meeting was recognition that the medical view was not necessarily the most significant contribution to whether physical abuse had taken place. There were the social factors of family life to take into account, the parent/child relationships, the role of the male in the home etc. which all would have added to the overall understanding of whether there was the likelihood of physical abuse within the home.

 

On the majority of occasions in these sorts of situation, the medical evidence is inconclusive, as it was on this occasion, but to then have accepted this to mean that the injury was accidentally caused, without further robust enquiries, represented that the “rule of optimism”24 was at play in this situation. It might help to prevent this occurring in future similar situations, if the medical view was presented as saying that on the balance of probabilities, the injury was likely to be the result of abuse, (according to research), rather than to report that an accidental cause was plausible.

 

 

(This is perhaps the Eileen Munro point – whilst one can adopt a safety first, child preservation approach and that might have saved Daniel Pelka, there is fallout in adopting such an approach across the board, that one ends up intervening at too high a level in other families where things would not have played out as they did here. Whilst the press would have social workers save all children such as Daniel, they are also quick to criticise where action is taken – see the recent headlines as a result of Re J)

I think the SCR do try to take into account the difficult balancing act that has to be undertaken, particularly in this section

14.7 This was a complex case for a number of reasons and it would be too simplistic to identify failings by individual practitioners as the reasons why Daniel was not protected. No individual practitioner works in a vacuum and that was true for this case in that the actions or inactions by individuals was at least partly informed by the management support and advice they received, the efficiency of the systems and processes within which they were working, the training they received, and their workload and organisational context. Nevertheless for future learning, it is important to try to identify some of the reasons why Daniel’s abuse was not recognised and acted upon earlier by practitioners who came into contact with him. These were likely to have included:

- Ms Luczak presented as plausible in her concerns, presented on many occasions as a capable and caring parent (when not in the midst of domestic abuse incidents) and took an assertive stance with professionals. Her manipulation, avoidance of contact with practitioners, deceit and actions (as well as that of Mr Krezolek) were not recognised for what they were and her presenting image was too readily accepted.

- Ms Luczak’s male partners did not regularly present themselves to practitioners and were hardly ever the focus of proactive intervention or enquiry.

- There were no specific concerns about the care of either Anna or Adam; in fact at times they were viewed as well cared for. This did not fit with the pattern that neglect usually impacts upon all children in a family.

 

- It is relatively rare in cases of child abuse that one child is singled out and scapegoated in the way that Daniel was. The apparent good care of the other children appeared to give a false reassurance that Daniel’s problems were not related to abuse.

- Daniel’s presentation of scavenging for food and his excessive eating when he found any sort of food, as well as being linked to weight loss, was rare to see in a child, and assumptions were then too readily made that his problems were medically based.

- Compared to other forms of abuse, emotional abuse is the most difficult to detect.

- In these circumstances, the practitioners involved were not prepared to “think the unthinkable” and tried to rationalise the evidence in front of them that it did not relate to abuse. The words of a philosopher were particularly relevant in this case in which he says “we see things not as they are, but as we are”42. If practitioners were not prepared to accept that abuse existed for Daniel, then they would not see it.

- No concerns were expressed about the care of Daniel to CLYP or to the school by neighbours or the community. If there were, then these might have added weight to the mounting concerns.

- Neither Anna nor Daniel ever expressed any concern about their care at home.

- Multi agency child protection systems such as Joint Screening for domestic abuse, Strategy Meetings, recording requirements and assessment practice, sometimes failed to support effective coordinated interventions between organisations and practitioners.

14.8 The above list is not meant to explain away the lack of protection that Daniel was afforded by professional interventions, or to give excuses for such practice. It aims to give some possible insight into the way that a particular set of circumstances and dynamics can lead to referrals for child protection not being made and ineffective interventions undertaken which are not sufficiently child focussed, by practitioners who were otherwise committed in their wish to address Daniel’s needs and protect him. Unlike the UK, some countries have a process for mandatory reporting of child care concerns to government departments43, which raises the question that if it existed here, whether injuries seen upon Daniel would have been independently reported by individuals to the authorities

The Lessons Learned are interesting, but one can’t help but read them with a heavy heart, thinking how many times other such Serious Case Reviews or public inquiries have said that we have to learn these lessons.

Is it that workers on the ground aren’t implementing these lessons and taking them on board, or is it that in order to balance a system where the actions of unpredictable people have to be predicted and anticipated and where the State is urged simultaneously both to leave children at home and to remove them, sometimes things will go horrendously wrong?

15. Lessons Learned

 

15.1 When concerning childcare incidents take place or a crisis arises for a family, these provide key opportunities to intervene at a time when parents may be responsive to change, or children are able to speak of their experiences. To not take proactive interventions at such times will create missed opportunities to protect the children, which may not recur again in such circumstances. Each opportunity which presents itself to protect a child must be taken.

15.2 Reassurances by parents about domestic abuse ceasing and that the children are not affected, need to be robustly challenged and responded to with respectful uncertainty by professionals.

15.3 Sole reliance on a parent’s explanation of events and views about family relationships and associated risks to the children, must be balanced with the presenting objective information available or evidence sought to support or challenge parental assertions. To not do so will potentially leave children at continuing or un-assessed risk.

15.4 Domestic abuse/violence is always a child protection issue and must always be approached with this as the mind-set of professionals.

15.5 No assessment of risks within a family or to a particular child can ever be effective without direct engagement of that child as an integral part of the professional interventions, and in working hard to gain an understanding of their experiences, wishes and feelings. There must be a child focus to all interventions.

15.6 To focus on concerning incidents in isolation and only deal with the “here and now” will not make it possible to take a holistic approach and therefore consider other similar incidents or other concerns at the same time. To be too incident-focussed will mean that the ability to develop an understanding of patterns of behaviour and family lifestyle will be seriously compromised.

15.7 Professional accountability for record keeping, timely reports and recording of key actions from multi agency meetings, is central to professional childcare practice, and to fail to complete appropriate records will significantly compromise inter agency working and reduce the collective ability of agencies to protect children.

15.8 Any facial injuries to a child must be viewed with concern, with physical abuse needing to be actively considered as a possible cause, and clear records, interventions or referrals made accordingly. To have no efficient system to collect and collate details of such injuries and actions will compromise later attempts to protect a child.

15.9 Even small units of service delivery to children and families, such as small schools, require a robust system to ensure collation of child protection concerns and appropriate actions, rather than rely on informal forms of communication within a small staff group.

15.10 Whilst a prominent injury to a child will inevitably attract the greatest professional attention (as occurred with Daniel’s fractured arm), the injury must be seen in the context of any other injuries or bruises, however minor they may be, and for their causation to be separately and then collectively considered.

15.11 For professionals from Children’s Social Care or the Police to defer to medical staff for the provision of the primary evidence to confirm or otherwise whether an injury to a child was the result of abuse or not, could be unhelpful, particularly when no definitive view one way or the other can be given. To do so could lead to any following investigation being inappropriately downgraded and implies that other aspects of the child life are less significant for the purposes of assessing the existence of child abuse.

15.12 When faced with significant and complex concerns about a child‘s welfare, it is essential that professionals “think the unthinkable” and always give some consideration to child abuse as a potential cause of the presenting problems. To not do so would be a disservice to the child involved and potentially leave him/her at increasing levels of risk.

15.13 Professional optimism about a family and of their potential to change or improve their parenting must be supported by objective evidence and that any contra indicators have been fully considered prior to any optimistic stance being taken.

15.14 For any professional to make a decision about their own interventions based on assumptions about the actions or views of other professionals without checking these out, is professionally dangerous practice.

Serious Case Review in relation to Kaiya Blake

Manchester have just published the Serious Case Review in relation to Kaiya Blake. Kaiya was four years old when she was suffocated by her mother, Chantelle, who was convicted of manslaughter in November 2012.  The mother was diagnosed as having suffered from Paranoid Schizophrenia at the time of Kaiya’s death.

The Serious Case Review can be found here :-

http://www.manchesterscb.org.uk/docs/Child%20U%20SCR%20Published%20Overview%20Report%2028-2-13.pdf 

The purpose of a Serious Case Review is to look hard at the involvement of all professionals and consider what lessons can and should be learned over and above the particular circumstances of this case.

The facts involved here are tragic, as is the case with the death of any child, but moreover because the mother was clearly unwell and in need of help and there were multiple agencies involved with her and that help did not reach her and Kaiya.

I don’t want to bash professionals – I’m sure that nobody involved feels anything other than utterly devastated about what has happened, and the last thing they need is a kicking from anyone else. Especially some smart alec with the benefit of hindsight.  But yes, there are lessons to be learned.

Three years before Kaiya’s death, concerns came to light about her mother, with reports that she was hearing voices and expressing that Kaiya (who was a toddler) wanted to have a sexual relationship with her. At that stage the issue of ‘cultural issues’ was raised, with professionals being asked to handle matters sensitively.  On investigation, the mother was disclosing that her light bulbs were giving her messages.  Over the course of the next few months further issues of the mother claiming that her neighbours were following her, stalking her, digging holes in her garden came to light.

In January 2009, mother acknowledged that she was a user of cannabis. In February 2009 the mother was saying peculiar things to other users of the Sure Start children’s centre, particularly to Muslim parents.  In July 2009, she visited the police station with Kaiya and told them that her television was laughing at her and making sexual innuendos to her.  Kaiya was placed into foster care, following Police Protection and was returned the next day. At the return, the mother became agitated that Kaiya may have been sexually abused in foster care and stripped her to check for any signs of abuse.

In April and May of 2010 further peculiar remarks were made by the mother, including “all children are drawn to me because I’m a Pisces and in the bible”  before going on to talk about children being stabbed at school and that she would be home educating Kaiya.

On 23rd July 2010 the GP was asked for an opinion on the mother and expressed that there were no mental health problems, although in 2005 she had been diagnosed as having a schizoid personality.

There were real difficulties in getting mother’s case dealt with by mental health services, and on 16th August they closed the case.

On 13th October 2010, three members of the public rang the police, after having seen the mother hit Kaiya hard about five times outside a supermarket. The police took Kaiya into police protection, and she went into foster care.

 At contact, the mother stripped Kaiya down to check whether she had been sexually abused. Kaiya told the social worker on the drive to the foster carers that her mother slaps her when she doesn’t listen.

 The social workers had planned to return Kaiya to mother’s care on 14th October, but were persuaded by the police to hold a strategy meeting. This took place on 18th October and the outcome was that mother was cautioned and Kaiya returned to her care. The mother had admitted slapping Kaiya.

 On 9th November 2010, at the children’s centre, Kaiya called her mother a derogatory name, when workers asked her to apologise to her mother, Kaiya said “my mum hits me”

 On 15th December, during a visit by Housing officers mother presented aggressively and displaying paranoid thoughts about her neighbours. There were ongoing incidents of worrying behaviour at children’s centre. Further attempts were made to get mental health services to assist mother and get a diagnosis of her, but in August 2011 the mental health assessment was that mother had no mental illness and closed the case.

 On the evening of 22nd September 2011, the mother presented at the accident and emergency department of her local hospital with self-inflicted injuries to her wrist and neck. She was assessed at risk of further self harm, and was seen by an Emergency Medicine Registrar (EMR) for assessment. She  informed medical staff that she had cut her wrists and ankle with a knife as she wanted to end her life; also that she had taken approximately ten paracetamol the previous night and drunk half a bottle of rum that day.

She  went on to say that she ‘did what she did because it needed to be done’, and that ‘the system was corrupt; Social Workers were treating her badly and had taken her daughter’. When asked where her daughter was, she informed medical staff that she was dead at home because she had suffocated her on Tuesday evening. The EMR noted that when disclosing her actions, the mother  showed no signs of regret and was very calm in her demeanour.

The conclusions of the Serious Case Review were, broadly:-

 That there became a preoccupation with obtaining a diagnosis of mother’s mental health and a paralysis once the mental health services were saying that there was no mental illness, rather than focussing on the impact of her behaviour on the child and the risk to the child.  

Whilst on occasions tenacious efforts were made by the Social Worker to achieve mental health assessments, there are two very significant issues for this review. Firstly, two months prior to the death of Child U, MU was assessed by an experienced psychiatrist as having no symptoms indicative of a serious mental illness following a comprehensive assessment. Secondly, each time medical opinion was sought, the outcome was similar, and MU was not considered to have any enduring mental health problems. This left professionals with a dilemma, if MU’s behaviour was not influenced by compromised mental health, why did she act and communicate in an abnormal manner? This question does not appear to have been faced, as ultimately the conclusions could lead only to one of two outcomes, either the medical diagnoses was incorrect or MU had a personality profile that was damaging to those around her, in particular Child U. Either conclusion needed a challenging approach to either health professionals or MU herself. Instead what appeared to happen is that the absence of a formal mental health diagnosis became the arbitrar of the response to the concerns 

That the preoccupations of the mother with sexual abuse in relation to Kaiya were not properly addressed or explored.

That the  physical abuse that had led to Kaiya coming into care in October 2011 was almost completely overlooked or sidelined at subsequent meetings or planning for the child protection plans

The description of the incident by three members of the public was one of a calculated and ferocious nature, and clearly indicated MU’s ability to cause deliberate harm to Child U. In would appear that the focus of the work became on engaging MU, and because MU was considered to have a difficult and volatile personality, achieving any degree of engagement with her was seen a measure of success in itself. This is evidenced by the summary of the Review Conference in February 2011 which stated that MU was now taking advice on board, when in reality no progress had been made.

[This is the rule of optimism that so often dogs Serious Case Reviews, where small improvements or changes are seized upon as evidence that support has made the necessary changes] 

That mental health services had not been sufficiently alert about the history and presentation

The subsequent letter from this assessment sent to the general practitioner was wholly inadequate in terms of identifying fully the reasons for the assessment, the mental state examination at the time of the assessment and documenting much more clearly as to how they had reached their decision not to offer any services.

The mental health services should have been significantly concerned about the evidence of psychosis they found, and this in combination with her apparent lack of insight, and the involvement of her vulnerable child in her delusional system should have rang alarm bells.

 That the opportunity to take action after the episode of physical abuse in October 2011 had not been grasped

No medical took place of Child U during this investigation, the rationale being that MU had admitted causing the injury; however, Child U could have had other undetected injuries. Given three people describing a sustained and severe assault, the decision not to have a medical was flawed and does not accord with good judgment.

 

10.6.5 This second use of police emergency powers led to an Initial Child Protection Conference being convened, as stated, outside of agreed timescales. It is worthy of note that Child U was not seen by a Social Worker until after the Child Protection Conference, and no home visit was made in the intervening period when MU had just been cautioned for assault

That the child was not seen alone sufficiently (another recurring theme of Serious Case Reviews)

Given what was witnessed, and what Child U said, the decision to return Child U to MU seems to have been made with undue haste. A further period of foster care would have allowed time for a deeper assessment of risk, and to work with both Child U and MU from a safe position. In the event, the comments of Child U were never discussed with MU and Child U was seen only twice alone during the period of the Child Protection Plan. The Children’s Social Care IMR reflects that this represents poor judgement and a lack of robustness in managerial oversight.

 

10.7.3 There are a number of occasions where Child U should have been given the opportunity to speak with a Social Worker alone and this did not appear to happen. It is a requirement when undertaking Initial and Core Assessments that a child is seen as part of that assessment and good practice that where it is age appropriate that a child should be seen and spoken to without the parent present. The Initial Assessments in July 2009 and July 2010 record that Child U was seen but do not indicate that she was seen alone or spoken with. The Initial Assessment conducted in June 2010 refers to Child U being asleep at the time of the Social Worker’s visit and therefore there were no observations or specific communications

 

 

The Case Conference system did not work as well as it should have done to pull together professionals and identify risks and a child protection plan

From the point of the Initial Conference, multi agency working together arrangements were compromised for a number of reasons:

• Not all relevant agencies were invited to attend the Child Protection Conference;

• The Child Protection Plan was misguided by a lack of focus on the specific issues of concern;

• The Core Group arrangements did not work well both from an attendance perspective and a lack of common understanding of what needed to be the focus of change;

• The Review Child Protection Conferences did not systematically reevaluate the causes for concern and what had or had not been achieved through the Child Protection Plan;

• The route into mental health assessment and services are not commonly understood or applied by professionals.

 

And most importantly, that the decision to return Kaiya to her mother’s care in October 2011 was not a safe one

 The evidence does not support the decision for Child U to return home so quickly following a significant assault without any depth of understanding as to whether Child U would be safe. IMRs from both GMP and Children’s Social Care acknowledge this to be a decision that cannot be easily understood, and the absence of any contemporaneous minutes from the strategy meeting further exacerbates the lack of explainable rationale. This is a critical error of judgement and the most important missed opportunity to better protect and robustly assess any ongoing risk to Child U.

 

The Review concludes that whilst Kaiya’s death was not predictable given what was known at the time, there were clearly risks present to Kaiya and more should have been done to act upon those risks.  A little like with Baby P, social workers were relying on a medical expert to give them a diagnosis (a paediatrician missing a broken back, a psychiatric service not spotting paranoid schizophrenia) but there were other opportunites to take action and take better stock of the risks.

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