The murder of two-year-old toddler Sanam Navsarka may have been prevented if not for the failure of Kirklees looked-after children’s staff to refer concerns received four weeks before her death to child protection colleagues.
That was the damning verdict of a serious case review published yesterday by Kirklees Safeguarding Children Board into Sanam’s death in May 2008.
Mother jailed for manslaughter
In February this year, her mother, Zahbeena Navsarka, then aged 21, was jailed for nine years for Sanam’s manslaughter, while Navsarka’s partner, Subhan Anwar, also 21, was imprisoned for a minimum of 23 years for murder.
Though Navsarka had not been in care, the review found different parts of Kirklees’ looked-after children’s service were working with different members of the wider family.
Four weeks before her death, concerns about Sanam’s welfare were raised with different looked-after children’s teams, including reports of bruising and that Anwar may be hitting her. Navsarka’s sister was among those to raise concerns.
However, instead of referring the concerns directly to the duty and assessment service, in line with child protection procedures, practitioners told Navsarka’s sister to pass on the information herself.
‘Poor understanding of responsibility’
The review said this suggested “a poor understanding of the wider responsibility to take action when a child is suspected of being abused”, and that the “focus of the individual staff members in the looked-after children service was solely directed towards the young people in the looked-after system”.
It added: “If those concerns had been reported, it is likely that protective measures would have been initiated that may have changed the eventual outcome.”
It said that it was likely looked-after children’s teams working with the family had information that was “not shared, recorded or considered as a whole”, that would have informed an understanding of Sanam’s care as Navsarka started a new relationship with Anwar.
Case recording and supervision rapped
The review also said “recording practice within some agencies was unsatisfactory” and in some instances did not comply with government standards, while poor supervision was identified in a children’s home and youth offending team involved in the case.
The review found that a “clearer commitment to supervision might have identified the concerns about the child and prompted an appropriate child protection referral”.
Overall, the SCR found Sanam was “not the focus of intervention, which was instead directed towards the adults, or towards other young people within the family for whom staff had a particular responsibility”.
It added: “Ultimately, the child was not sufficiently visible to prompt individual professionals to report concerns that she had been seen with a bruise and a mark to her head and that the mother’s partner was believed to be hitting the child.”
The review said agencies should report to the safeguarding board within six months about the steps they have taken to make professionals aware of their responsibility to pass on referrals to the appropriate team, and to ensure systems are in place to monitor supervision and staff child protection competencies.
It said staff at all levels in residential care and the looked-after children and leaving care teams should receive further training in child protection procedures and recognising and passing on safeguarding concerns.
It also said the council’s children’s social care service should also introduce a quality assurance mechanism to ensure records are being maintained to a high standard.
Kirklees Council’s director for children and young people, Alison O’Sullivan, apologised for the looked-after children’s staff’s failure to follow procedures, describing it as “a lapse in our usual standard of professional practice”.
She said two staff had faced “very serious sanctions” following a management investigation, adding: “We have reinforced with all of our staff the importance of always following procedures. Certain groups of staff have received retraining and we will continue working vigilantly to ensure a lapse like this cannot happen again in future.”
Karen Hemsworth, vice-chair of the safeguarding board, said agencies were already acting on its recommendations on improving the monitoring of supervision, case recording and child protection comptencies.
Expert guide to the Laming child protection review