Haringey council has been criticised for not following up child protection concerns despite “such obvious cause for concern” in the case of a young person who took her own life.
The Haringey Safeguarding Children’s Board serious case review into the death of Child O, who has been identified as Mary Stroman, said child protection implications of the overall situation were not pursued, and that concerns over whether the girl was sexually exploited were at times not followed up by children and young people services.
Services were criticised after they reached “unevidenced conclusions”, which included dismissing “early disclosures by Child O of sexual exploitation on the basis that they were incredible and probably a consequence of O’s ‘mental health issues’”.
Stroman died in January 2014, aged 16, after four years of involvement from services. She had post-traumatic stress disorded caused by episode(s) of sexual abuse, which was identified in a coroner’s hearing last year. She self-harmed and disclosed suicidal thoughts throughout the four years covered by the review.
Child protection response
“The circumstances of Child O’s situation required a formal child protection response and, within that, a consideration of the specific guidance on children who are being sexually exploited. No agency identified this and pursued it. This is perhaps further evidence of the way in which the disagreement between agencies about admission to care diverted attention from the fundamental processes of assessment and review,” the review said.
It added: “Even without reference to this specialist guidance one would have expected a formal child protection response in the light of Child O’s extreme behaviour and the extent to which her parents struggled to control her and protect her from the potential consequences of that behaviour.”
The local authority resisted placing Stroman in public care, the review said. She was eventually placed in a residential therapeutic school in Wiltshire, until her death. Concerns were raised about the decision by the council to cancel this placement following an inadequate Ofsted judgement, without consulting Stroman or her family who had gone on holiday. She was eventually allowed to return to the placement.
A total of 21 agencies, including the police, NHS trusts and clinical commissioning groups were involved in the serious case review, which raised concerns that a number of issues raised in a 2013 serious case review, which looked into the circumstances surrounding the abuse of a child that should have been prevented earlier, had re-appeared in this case.
The council was criticised for responding slowly and failing to provide “any written explanation for their decisions and actions” to the family.
Paul Ennals, independent chair of the safeguarding board, said it has started acting on the reviews’ recommendations, which it accepts.
“She did not normally find herself able to trust people, and perhaps the greatest sadness that staff from all agencies express is that, despite so many people working with her closely over several years, nobody can feel sure that they truly understand what was at the heart of her unhappiness,” Ennals said.
On the arranging of Stroman’s final placement: “The quality of joint working between the council and the relevant health commissioning group, who were sharing in the costs of the placement, was poor, particularly from the local authority that provided two thirds of the funding. There has been clear learning for the local authority and its partners from this episode, and improvements have been introduced to the systems for jointly commissioning any future very high intensity placements.”
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