suesspiciousminds

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 23^rd 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 16^th August they closed the case.

On 13^th 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 14^th October, but were persuaded by the police to hold a strategy meeting. This took place on 18^th October and the outcome was that mother was cautioned and Kaiya returned to her care. The mother had admitted slapping Kaiya.

 On 9^th 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 15^th 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.