A clear chronology of events in a safeguarding case can show agencies where risks lie. But it can be hard to find the time to do them, reports Camilla Pemberton
In 1973 a seven-year-old girl was pushed to hospital in a pram by her mother and step-father. Badly bruised and suffering with severe internal injuries, she was pronounced dead on arrival. The cause of death: a beating from her step-father. It followed months of abuse and neglect.
The child’s name, Maria Colwell, will always be synonymous with human cruelty and professional failure. After being fostered for several years, Maria returned home to her mother and step-father. She was known to the NSPCC and social services, but warnings were missed, or dismissed.
The circumstances of her death highlighted many lessons. One concerned the importance of keeping chronological records of significant events in a case. If managed properly, a chronology could have built a picture of Maria’s history and the risks posed to her.
Abuse and neglect is “infinitely more preventable” when good chronologies are kept, says Tink Palmer, chief executive of sexual abuse awareness charity the Marie Collins Foundation. “Patterns in social history and behaviour can be detected and something which might appear insignificant in isolation can be identified as a key warning sign in context.”
Chronologies can be a really successful risk assessment tool, agrees Nushra Mansuri, professional officer for the British Association of Social Workers. “They can highlight people in the child’s life already known to agencies because of previous concerns and reveal the nature of current relationships between families and their wider social networks.”
Yet more than 30 years after Maria’s death it seems chronologies are still not always managed properly and key opportunities to intervene are being missed.
The damage is not just apparent in high profile cases: Professor Elaine Farmer, of Bristol University, cited inadequate chronological recording as a factor in multiple failed returns. Failed returns are deeply disruptive for children, Farmer says, but her research also revealed something more sinister. Like Maria Colwell, two-thirds of children who returned home after a period in care were abused or neglected again. “We urgently need ways of making sure a child’s history is visible and easy to access,” Farmer told Community Care.
Pressures of work
Practitioners are not being deliberately negligent. Pressures of work and the level of attention expected to be given to the case, for example in a court, can influence how chronologies are prepared. “Social workers often do good chronologies in court but sometimes, in cases that won’t get as much attention, they can seem to slip off the agenda,” says Lucy Titheridge, team manager for Sutton Council’s referral and assessment service.
Palmer points out that caseload pressures can lead to significant events being missed. “The reality is that if someone is exhausted and under pressure, they may forget to ask certain questions, or dig into things which don’t seem to be child protection issues”.
“Social workers need time to engage with families and gather the good quality information needed to produce a chronology,” says Mansuri. “My concern is that they are not being given this time. Inevitably, this leads to criticism when chronologies are either missing from reports or full of inaccuracies.”
In some cases, technology is exacerbating the problem. The Integrated Children’s System (ICS) “has not achieved what it should have in terms of chronologies,” says Steve Liddicott, ICS expert panel chair, adding that the panel often hears it “has made life more complicated in this area”.
“Trying to establish a narrative from a computer screen of a case history can be daunting,” says Robert Fitzgerald, children’s services product manager at ICS provider OLM Systems. “Often there’s too much information in the system.”
Changes to some councils’ ICS systems are helping social workers to keep well-managed chronologies. Nichola Bennett, a senior practitioner in Camden Council’s looked-after children team, says: “When we write up case notes into our ICS, we now press a button labelled ‘significant event’ which automatically transfers that information into the chronology. The up-to-date chronology can then be printed out in full. It’s very easy-to-use.”
Fitzgerald points out that it will always be practitioners who must determine “the key events in a case and the degree of impact on the child”. Learning what should be transferred into a chronology is an important skill which managers must help social workers to develop, Bennett says.
To do justice to chronologies, says Mansuri, social workers must spend time with families. This involves, “reclaiming legitimate space for social workers to do good direct work”. “We also need to recognise that a chronology needs to be updated and may take more than one visit to complete, but we need to subvert the system if it is not working for us,” she says.
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Khyra Ishaq’s death
How key events revealed a pattern of risk
The chronology included in the serious case review on the death of Khyra Ishaq revealed a pattern not apparent to disparate agencies:
2 May 2001: Khyra Ishaq born
15 December 2005: Khyra and sibling fail to attend a child development appointment. This was one of several cancelled appointments. Information was not shared.
1 March 2006: Pattern of defaulted appointments emerging.
28 February 2007: Health visitor makes a referral to children’s services following reports from Khyra’s mother that the father is abusive.
20 March 2007: Mother meets school to discuss concerns that Khyra had been stealing food. School agreed a behaviour support manager would observe Khyra. Information was not shared.
6 December 2007: Mother tells teachers Khyra will be home-schooled.
19 December 2007: Deputy head of Khyra’s school contacts social services. She and a colleague do a home visit but are refused entry.
19 December 2007: Child protection referral made by deputy head, but delays occurred due to staff capacity. Later, two teachers visited Khyra’s home. Mother refused them entry.
28 January 2008: Education social worker (ESW) visits Khyra’s home. There is no answer. Deputy head also contacts children’s services for the third time regarding concerns.
30 January 2008: ESW calls children’s services following a home visit. Social services suggested a Common Assessment Framework, which ESW recorded was inappropriate due to mother’s resistant attitude to professionals.
8 February 2008: An ESW and council mentor visit Khyra’s home. They do not see Khyra.
21 February 2008: Two social workers on a pre-arranged visit are refused entry to Khyra’s house. Khyra and some of her siblings are brought to the door and the social workers report they have no concerns for the children’s well-being.
17 May 2008: Khyra pronounced dead at Birmingham Children’s Hospital, from an infection caused by starvation.
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