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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.

 

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Inquiring minds wanna know (part one – Orkney)

 

 

A review of some of the major child protection public inquiries, to see if the things we were supposed to learn from them really were learned.  This one – Orkney.

 

 

As we all know, social workers in every single case either act incompetently and bungle their simple job by leaving children to be abused, or act like jackbooted fascists, snatching children from their loving families on flimsy evidence. This is all based on the media reporting on social workers. The fact that from the media reporting on doctors, the general public don’t perceive that all doctors are either pioneering geniuses who have invented a new cure for cancer OR filthy perverts who touch up their patients at the slightest pretext, is probably because the average person reading a paper has a real life GP with whom to compare those stories and work out that the average GP is just someone doing a job – they may do it well, or badly, they may have days when they do particularly well or days when they’re just not at it. But the average person doesn’t know a real life social worker (since all social workers like lawyers, routinely lie to people in pubs about what they do for a living, to avoid the look of disappointment/revulsion/boredom on the other persons face) and so haven’t got that recalibration of  “the ones in the papers are in the papers precisely because they are an exceptional example, for good or ill, of their profession, and you can’t extrapolate from that what the average member of that profession is like”

 

I liked in the first Munro report, the honesty that you simply can’t create a system that both protects every child from harm and at the same time protects every innocent family from disruption. The profession for a while, and the media, are under the illusion that people can get that decision right – is this safe, or am I being intrusive? In 100% of cases, and it just isn’t true. More information and more rigorous assessment helps get it right, but it won’t ever get it right 100% of the time. Just as doing surgery on people carries with it an inherent risk that something will go wrong, but we don’t have a media outcry to ban heart surgery when a patient doesn’t make it through the operation, balancing risk against the desire to keep families together isn’t going to be a judgment call that is right all the time.

 

The public inquiries have focussed on the two areas where social workers and other child protection professionals have got it wrong  (nobody ever held a public inquiry to see which of the people involved in brilliant work most deserved the credit – they are by their nature a blame game)

 

They fall into the “How could anyone have missed that?” school  – Maria Colwell, Paul, Victoria Climbie, Baby P  or the “what on earth were these people thinking?” school   – Cleveland, Rochdale, Orkney.

 

It struck me this week that the family justice system probably has a significant batch of people now who weren’t reading newspapers and watching the news when Cleveland or Orkney were happening (they were over 20 years ago) and probably very very few who were in practice when the Maria Colwell report came about.

 

So, a short series of blogs reviewing those public inquiries, and the lessons that were intended to be learned from each of them, and then an overview of whether those lessons really have been learned, or whether the public inquiry is anything more than a political way of saying “We’ve tackled this, public, no need to worry about it any more, move on”

 

 

 

ORKNEY

 

The actual inquiry can be found here :-

 

http://www.official-documents.gov.uk/document/hc9293/hc01/0195/0195.pdf

 

 

On 27th February 1991, nine children from four families living on the island of South Ronaldsey, Orkney, were removed from their families by the social work professionals of Orkney.

 

They were removed principally because of allegations made by three children of another family, the W family.  The nine children remained in care until 4th April 1991, so were in care for just over a month. They returned home because a hearing before the Sheriff’s Court dismissed the application for technical reasons but had expressed strong views that regardless of the technical issue in his view the children should be returned home. The Local Authority won an appeal against that decision, but the children had gone home by that stage and the Local Authority abandoned the proceedings.

 

It is worth noting that the public inquiry did not tackle the merits of the allegations or whether they were proven, and this led to some disquiet amongst the family members involved, who had been the subject of truly ghastly allegations which were never really laid to rest or the families innocence being fully acknowledged.

 

The W family had been known to Social Services for a number of years. The father of that family had been convicted for offences of physical abuse against his children and had pleaded guilty to criminal charges of sexual abuse against his children in 1987 and received a seven year prison sentence as a result.

 

The Local Authority were therefore working with the children of the W family, particularly as a result of allegations of sexual abuse between the siblings of the family and child protection court proceedings were taken as a result. [I am not going to dwell, in this summary, on the different processes in Scottish law and English law unless it becomes explicitly relevant – suffice to say that proceedings were brought)

 

The mothers of the other families involved Mrs M and Mrs T were close friends with Mrs W, and the social work professionals began to note that when they made visits to Mrs W, the other two mothers would be present and Mrs W wanted them to remain, even when professionals suggested they should leave.

 

On 30th October 1990, a child OW, made allegations of sexual abuse against siblings. This was shortly before OW’s 16th birthday. The LA were aware that other older siblings had made allegations of inter sibling sexual abuse at a similar age and had then retracted them.  A Place of Safety Order was obtained for OW, and over the next weeks, the Local Authority came to believe that all seven of the W children who were under 16 should be taken into care.

 

During the removal process the youngest child, SW, was not initially found and removed and there was some suggestion that other families on the island were assisting in her being kept away from the LA. The child was found by the police in the care of a Minister.

 

The seven W children came into foster care, with court proceedings, and medical evidence was obtained that suggested that the children had been the victims of sexual abuse, this abuse post-dating Mr W’s incarceration – thus that there was still abuse taking place and a live risk to be protected from.

 

South Ronaldsey was a relatively small and isolated community, and there was a considerable amount of local feeling that the W children had been wrongly removed. There was a large volume of correspondence being sent to the LA in relation to the W children, both about them, and for them.  The letters contained references to turtles that the LA did not understand, and there were also gifts including toy turtles.

 

The W children were interviewed about their disclosures – thought had been given to video-recording the interviews, but due to a combination of technical problems and the children’s reluctance to be recorded, this did not happen, and the disclosure interviews were conducted with a written note being kept. There were a number of interviews and there was some uncertainty between professionals as to whether the purpose of these interviews was forensic (to gather evidence about the abuse) or therapeutic.

 

Initially the disclosures related to inter-sibling sexual abuse and wholly unacceptable sexual boundaries within the sibling group.

 

But on 6th February 1991, the disclosures from MW took on an entirely different character. The allegations became of a form of abuse which was organised in nature, in the open-air at a quarry, involving a number of different adults including the minister, and which had a ritualistic overtone, with cloaked figures and a circle, with a child being chosen, pulled into the centre of the circle with a hook (similar to a shepherd’s crook) and abused whilst everyone else watched. The disclosure was detailed and accompanied by the child making drawings about what was alleged to have happened. The police officer present later said that she had not believed the allegations until MW had said “my dad will kill me” which made the police officer feel that the allegations were true.

 

The contemporaneous notes made by the police officer in a ring notebook were subsequently shredded, although a handwritten note based on the contemporaneous notes was made.

 

MW gave a further interview on 12th February, developing the detail and adding information that the children had had to wear costumes, including turtle costumes.

 

QW also gave an interview that day, in which she was asked about the turtle suits and went on to make similar disclosures to MW.  (of course the critical point here is that there were six days between the first interview where MW made disclosures of this type and other siblings making similar allegations, six days during which there was opportunity for cross-contamination)

BW attended an interview the following day, and made the same disclosures about costumes, a circle, dancing, and individuals being pulled into the circle by a man with a hook and then abused whilst everyone watched.

 

The children were naming the same adults as being involved, and those adults had children of their own. The W children had named those children as having been involved as victims of the abuse.

 

[LW was interviewed on 13th February and did not make any disclosures, saying when questioned about the details that he did not know anything about this and had not gone with the other children, and that he had probably been at the beach instead. ]

 

It was felt, by the police and the Social Services department that as a result of these disclosures, there was significant concern about whether there was a form of organised abuse taking place in this island community, and that three children had made the same detailed disclosures naming the adults involved and that children from other families were suffering the same sexual risk as they were.

 

[Now, putting to one side, the problem of contamination and that the recordings made were flawed because they weren’t videoed, and weren’t conducted along the Achieving Best Evidence standards we – ha! Would see today,  the authorities here were in a tough spot – they were aware that the W children were very sexually disturbed children, that they had been the victims of sexual abuse from someone, and they were giving an account that was very detailed and consistent between them. This account implicated other adults and was that other children had been victims of this abuse. Those other children were living at home with those allegedly abusive adults. The authorities had to make a call as to whether to write off these allegations as being fantastical and lacking credibility, or whether to seek to keep the other children safe whilst that was being determined.  We know that history has deemed that they made the wrong call, and it is very easy to look at the workers involved and wonder with our hindsight what on earth they were doing believing these allegations.  But I certainly remember at that time – when I was working on the Child Protection Register, pre any thoughts of becoming a lawyer, that I’d often see the phrase in official documents “children must always  be believed” and that was certainly a part of child protection thinking at that time, that children did not lie about things as serious as this. If you consider that context – that professionals believed that children would not lie about this sort of thing and that three of the children, who definitely had been abused by someone, were saying this, one can see why professionals made what now in hindsight seems an obviously wrong call.  I haven’t seen the phrase “children must always be believed” for about twenty years..]

 

A variety of professionals held what we would now call a Strategy meeting, to discuss the disclosures/allegations and what to do as a result.  [As an aside, there’s always a very different, yet subtle distinction between the word ‘disclosure’ and the word  ‘allegation’  – disclosure implies belief that what is said is true – you don’t disclose something that didn’t ever happen, and allegation implies at best caution about whether something happened or not. Always interesting to watch at a Court hearing, who says ‘allegation’ and who says ‘disclosure’]

 

The social work manager made a remark at that meeting which probably haunted her for years afterwards, asking the police how much more evidence they needed in order to act, saying that there was ‘enough evidence to sink the Titanic’

 

By  the end of 13th February 1991, the decision had been taken that nine children named in those allegations had to be taken into care through the making of Place of Safety Orders.

 

You may, if you’ve been paying attention, recall that the children were not removed until 27th February 1991, which would have given two weeks for there to be some investigation with those children or those families. This time was used to plan the operation of removing the children simultaneously and arranging for foster placements, medicals and disclosure interviews. No doubt this was quite a logistical exercise – particularly given that all of the children would be being removed not only from their homes, but from the island on which they lived and would need to be transported to another island. The authorities were convinced that all of the children needed to be moved at once. This, I think, is where things really went wrong. If the W children’s allegations were wholeheartedly believed by professionals, and I’m sure they were, for the reasons earlier discussed, then how could you leave the children at the risk of organised and serious sexual abuse for another fortnight, once you had decided they had to come out? And if they were safe for a fortnight, why were the children not interviewed prior to any decision about removal?  (The LA might, conceivably, have been swayed by the knowledge that the W children had been in foster care since October 1990, and thus the last known allegations about the organised abuse pre-dated that removal, but this seems slender to me)

 The planning also included an intention that each of the children be placed separately, to facilitate any disclosures and ensure that siblings did not influence, contaminate or silence each other.

 

What seems almost extraordinary, twenty years later, is the passage in the inquiry report that says that at the time the decision was made to remove the children, the LA had very little information about the children, including the ages and number of children that the families under suspicion had.

 

The other families were not known to Social Services, save for the friendship some of the mothers had with Mrs W.

 

But here is the really damaging bit.  On 20th February (BEFORE the removal of nine children), MW was interviewed again about the organised abuse. During the interview, she observed to the interviewers  “Did you know this was all a lie?”

 

And at that point, before nine children were removed from their families, seven days after the decision had been made, but seven days before it had been carried out, THAT was the point at which all of this could and should have been stopped.

On 23rd February, four days before the removal, AW was interviewed. AW had not made any allegations about organised abuse, and when asked about it was adamant that none of this had happened.

 

In order to manage this situation, Orkney Social Services had asked for assistance from other Scottish local authorities, both in terms of placements and provision of experienced social workers with a background in investigation of sexual abuse allegations. The workers from those authorities gave evidence to the inquiry that they had understood that the evidence of abuse was compelling and robust and that the Orkney police had weighed all of this up. They had not been aware of the 20th February interview with MW when MW had said that this was all a lie.  It would be fair to say that those workers had a sense of considerable disquiet about the way in which the removal and post removal work was being planned, particularly about the removals being scheduled for 7.00am – one of the workers used the term ‘dawn raids’ to convey the dramatic and disproportionate nature of what was being proposed which was exactly the view the Press took of what happened subsequently.

 

The application forms for the Place of Safety Orders were completed, but gave no detail about the nature of the concerns or why the orders were sought. An application was made before the Sheriff Clerk at which only the LA were represented – this application dealt with four families and nine children. The hearing lasted, in total between twenty and twenty-five minutes.

 

The orders were made.  (It appears that there were at the time, two routes to obtain Place of Safety Orders in Scotland – one a hearing before a Sherrif Clerk, the other before a Children’s Reporter – and that the latter might have been more formal and robust)

 

At the final meeting before the children were removed, there were fifty professionals present, ten or fifteen were standing. It was loud and crowded, with people speaking at the same time and it was difficult to take notes. There were real concerns with both the Orkney field social workers and mainland social workers feeling that insufficient information about the nature of the abuse was being shared and that the plan to separate all of the children and provide no sibling contact was harmful in nature. Those concerns though expressed, did not result in any change of direction.  Matters became so heated that the mainland social workers were minded to pull out and not be involved in the operation – at eleven pm, this debate was still raging, and it was only when they were told that the removals would go ahead with or without their assistance that they decided it would be better for the children for them to remain involved.

 

The nine children were removed on 27th February, at around 7.00-7.30am. The parents were told that the children were being removed because of the families involvement with the W family, and that Place of Safety Orders had been made. They were told no more than that. The removals, as one would expect, were difficult and traumatic.  Some of the children ran away, some shut themselves in rooms, one of the mothers was clinging to a child and shouting at the social workers that they were evil. One of the police officers during a removal told the mother that she would go to Court and get the children back.   [Bear in mind that prior to this ‘dawn raid’ the families concerned had never even been VISITED by a social worker,  their first involvement was a removal without warning. Also, that the Place of Safety Orders served on the parents gave no information as to what would happen next and the parents were not formally  told of what their rights would be to contest this removal at Court, and also that some of the professional and experienced social workers later described the experience as “harrowing”]

 

The medical examinations showed no evidence of abuse.

 

The first Court hearing (The Children’s Hearing) to review that removal was 5th March 1991. The parents were served with notice of that hearing the afternoon beforehand. Now, bear in mind that this hearing was taking place on a remote island in the Orkney islands and what was at stake, and wince at this next bit.  The parents on the morning of 5th March, asked for some more time to be allowed for their senior counsel who were travelling from the mainland to arrive. The Court refused as members of the Court tribunal had taken time off work to come in that day. Eventually, the local MP was called and intervened, to secure an adjournment from 10.0am to 11.00am. The Court had allowed thirty minutes for each families case (!!!!) but in the event, the hearing (for four families and nine children) concluded at 3.00pm. Oh, also, none of the parents had seen any of the evidence against them, even at this stage. The broad nature of the grounds was shared with the parents half an hour before the hearing and they were asked whether they agreed with them, which of course, they did not.

 

The Court granted a Warrant which authorised the further detention of the children in foster care for 21 days. The parents appealed, and that appeal was dismissed on 7th March.

 

[I suspect that this is a theme I will return to, but in my view here, I think the Court is culpable and escapes criticism. Just as the LA took a view on the evidence and made the wrong call, so too did the Court.  If the Court had not sanctioned the removal on 5th March,  or indeed not granted the Place of Safety Orders on 27th March, or granted the appeal on 7th March, those children would not have been in foster care for a month unnecessarily]

 

Curators (like a Guardian) were appointed for the children, and they began investigating matters.

 

The Press became greatly involved, and the local Press named and provided photographs of the children. The case attracted a great deal of media interest and the Local Authority were roundly criticised for both the decision to remove and the manner in which it had been done.

 

A case conference was held, to which none of the parents were invited.

A second sitting of the Children’s Hearing took place on 25th March, to decide whether to extend the Warrant that was allowing the LA to keep the children in foster care. The Court allowed FIFTEEN minutes for each family! In the event, the hearings took much longer. At one stage, an application was made for Counsel and solicitor for Mr and Mrs M to be removed from the court room on the basis that the Acting Reporter  (sort of a cross between a Child’s Solicitor and a Legal Advisor to the Court)  considered they were being disruptive. They were asking the Court, somewhat forcefully, to consider the medical evidence that there were no signs of any abuse on the nine children that the LA claimed had been the victims of organised abuse (The modern reader might well consider that what they were doing was advancing their case that what was happening was a miscarriage of justice)

 

Warrants were extended for a further 21 days.

 

A hearing was fixed for 4th April – and it is at this point that Scottish and English law deviate – the parents argument here was that the case should be dismissed on the basis of Competency; which initially sounds like a submission that there aren’t reasonable grounds to believe that the allegations occurred and that there is thus no risk of harm; but actually is something more technical than that.  The application was to dismiss the case but if successful it would not result in there being anything akin to a finding that the threshold was not met, or that there was no case to answer. [Sadly, the inquiry doesn’t explain the technical aspect terribly well to someone not au fait with Scottish law in the early nineties, and even I am not sad enough to research it. I think it relates to the fact that the legal grounds that Orkney had used was that the police would be making arrests for criminal behaviour, which they didn’t, rather than on the legal grounds that the children had suffered abuse]

 

It is worth noting that one of the children EB was interviewed about these matters TEN times, in the month he was in care!  (I apologise for the exclamation marks, usually I am with F Scott Fitzgerald  – “Cut out all those exclamation points. An exclamation point is like laughing at your own joke” but really, I think they are justified here). Also none of the children had any contact with their parents or their siblings during this time.

 

The children were interviewed multiple times, and some of them did talk about going to dances where there were people with lanterns, and a circle and that a man danced in the middle of the circle and would pull people in to dance with him with a shepherd’s crook.  It simply can’t be known whether this was an account of some innocent activity that the W children embroidered with the florid accounts of sexual elements, or whether in the multiple interviews, the suggestions were made of these things having occurred so many times that the children were eventually agreeing that they had happened.  Some of the interviewers conducting the interviews with various children were conducting four or even six interviews per day.  I don’t think it would be unreasonable to suggest that this is far too much for a process which is emotionally draining on the children and the professionals involved.

 

On the morning of 4th April, the Sherrif dismissed the application for a further extension of the Warrant on the grounds of competency, but also said that in his view the children should be returned home. As indicated earlier, the competency argument is a technical one, not on the merits of the application. The LA successfully appealed that decision, but the children had gone home in the meantime and the LA took their first smart decision in a month and a half and decided not to seek further Place of Safety Orders.

 

On 15th July 1991, the children’s names were removed from the Register. The parents were invited to that Case Conference.

 

The inquiry sets out, after analysing all of the evidence, a Summary of Comments (which are effectively bullet points of bungling) 135 in all.

 

Key amongst them :-

 

The social work department failed to consider the children individually

They failed to keep a wholly open mind about the allegations made by the W children and allowed the investigation to be coloured by suspicions

They failed to consider the Cleveland report

They failed to have a proper case conference to which the parents were invited

They failed to keep a proper record of decisions and of disclosures

They failed to give sufficient thought as to whether it was necessary to remove the children

They failed to appreciate the significance that the allegations of abuse had not come from the children in question

The degree of risk to the nine children was not properly assessed

They acted too precipitately and failed to take time to pause and think

They should have reassessed the situation after the medicals showed no sign of abuse

The parents ought to have been given proper information about the Place of Safety Orders and their rights of challenge and the process

The parents should have had support from the LA after the removal, and much fuller information about the reasons for removal

The interview process was wholly ineffective for investigative work such as was in actuality being carried out.

 

RECOMMENDATIONS

 

  • Those involved in investigating allegations of child sexual abuse must keep an open mind and not fall into the trap of confusing the taking of what a child says seriously with believing what the child has said

 

  • Where allegation are made by a child concerning sexual abuse those allegations should be treated seriously, should not be necessarily accepted as being true but should be examined and tested by whatever means are available before being used as the basis for taking action

 

  • In cases of child sexual abuse, removal should not be undertaken unless both a rigorous objective assessment of the situation has been made and in addition rigorous planning to balance the risk inherent in intervention and removal against the prospects of success in the legal action

 

  • Parents should usually be informed that the suspicion exists and that it is being investigated , their cooperation should be sought and the investigation draw on information from every possible source

 

  • There should be clear guidelines, both nationally and within organisations as to how child sexual abuse allegations are to be dealt with

 

  •  Removal of a child should be considered where no alternative exists and the risk of the situation requires it, caution must be exercised and the gravity of the situation considered

 

  • The reasons for seeking an order should be set down in writing and made available at the time the order is sought

 

  • The child or parent should have an immediate right to challenge the making of that order

 

  • Guidance should be given on the need for maintaining contact with a parent after removal, even where there is considerable hostility from the parent

 

  • Siblings should be placed together unless there are compelling reasons why that should not be the case.

 

 

 

Most of these seem blindingly obvious and barely worth saying, but it is probably the case that the reasons all of these things happen routinely is in part due to the Orkney case.