A serious case review has found support for a family was “fragmented” in the lead up to the death of a seven-year-old girl.
Shanay Walker died from a brain injury in July 2014, two years after being placed into her aunt Kay-Ann Morris’s care under a special guardianship order. Morris and Shanay’s paternal grandmother, Juanila Smikle, were jailed for child cruelty in 2015.
Shanay endured a chaotic early life and had mild learning disabilities and kidney problems. She and her sibling were removed from their mother, Leanne Walker, in the wake of Walker suffering from post-natal depression and struggling to care for them.
The serious case review found a ‘light touch’ family assessment order (FAO) imposed after Shanay was placed with Morris meant no coherent plan for her wellbeing was implemented. Consequently, issues noted by various professionals that might have served as early warnings, including bruising and question marks over Morris’s care for her niece, were not shared.
At the time of Shanay’s placement with her aunt, Nottingham council had formed a separate family support team of specialist agency staff.
“This decision was taken to enhance the family support process, but had the opposite effect because the team became separate from mainstream work and planning,” the review found.
Shanay’s case was handed over to a family support worker from a social worker eight weeks after she moved in with her aunt.
Over the following two years there were numerous incidents of bruising, burns, other injuries and behavioural problems noted by Shanay’s school. While on many occasions these were recorded as having been passed on to children’s services, corresponding evidence to support this was often missing and the review concluded that information had not always been shared as it should have been under safeguarding protocols.
While the family support worker did discuss injuries to Shanay with her school’s safeguarding lead and agreed to share incidents in future, “the meaning of this was not explored and the FSW did not ask about what records were held”.
At the same time Morris’s “harsh” parenting style, which included physical disciplining, was noted. In spite of this, professionals remained focused on her version of events – in which Shanay was self-harming, “testing” her and deliberately bed-wetting – and mistakenly saw the problem they were dealing with as a behavioural one, the review found.
Confusion around changes to safeguarding arrangements at Shanay’s school exacerbated the issue and support from CAMHS was pursued rather than exploring child protection concerns.
Despite continued reports of “inappropriate disciplinary approaches” by Morris, the school was informed in June 2014, one month before Shanay’s death, that her case would be closed by children’s services. “Once again [her] needs were lost through entrenched, adult-focused views,” the serious case review said.
‘Manipulation and deception’
Professionals, the review noted, were “manipulated and deceived” by Morris throughout the two years Shanay lived with her. Recordings of meetings taken by Morris and subsequently examined revealed her dominance of proceedings.
“The level of cruelty was glimpsed, but not fully known,” the review found. It highlighted “the absence in this case, caused in part by the granting of an FAO, of routine processes such as ongoing assessments, plans which make clear the nature of a child’s needs and good multi-agency working arrangements, effective reviewing arrangements, clarity of task and role [and] an awareness that parents/carers who are abusing children create divisions and diversions so they are not found out”.
The family support worker was found to have “colluded” with Morris, taking her side against the school in order to maintain a relationship. “This must never happen,” the review concluded.
Among a series of recommendations, the review said that Nottingham City Safeguarding Children Board (NCSCB) should:
- Seek to better understand the implications of parental mental health problems and how better to implement support;
- Highlight the importance of recognising and understanding early childhood trauma, including ensuring that this is communicated to partner agencies;
- Update its practice guidance around young children and self-harm;
- Review guidance for all professionals regarding the assessment of potential non-accidental injury and ensure it is compliant with NICE guidelines regarding child maltreatment.
Commenting on the serious case review, NCSCB chair Chris Cook said: “While professionals had Shanay’s wellbeing at heart, with the benefit of hindsight it is clear they could have displayed more professional curiosity about issues and incidents which emerged.”
Cook added that the NCSCB had made recommendations to address issues around identifying and reacting to potential self-harm and non-accidental injuries among children, responding appropriately to other health issues and ensuring that the role of schools in safeguarding children is recognised and reflected in multi-agency practice.
“We are satisfied that appropriate changes are under way or have been implemented, and that all agencies would now be more focused on how their collective actions impact and benefit the child,” he said.