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The history of care has always been signposted by tragedy and scandal. Indeed, we all know that the only time you can guarantee coverage of social care in the media is when things go horribly wrong. But the ability and willingness to learn from mistakes is a great social work characteristic. Each avoidable child death or uncovered systematic institutional abuse has changed our thinking, jolted our accountability and improved our practice. And yet we continue to make the same simple mistakes. If our practice is to best protect children, young people and vulnerable adults we need to start paying proper attention to our history. And that means getting the basics of practice right. First, Graham Hopkins looks at the history of child death inquiries from 1945 to the present day and picks out the recurring themes. And, then Grant Wetherall, who went undercover in the notorious Longcare homes for people with learning difficulties, finds lessons from earlier scandals that could have help avert last year’s Cornwall scandal.

On 28 June 1944, Dennis O’Neill, who had been in the care of Newport Borough Council for nearly six years, was placed into foster care at the 70-acre Bank Farm in Minsterly, Shropshire. His younger brother Terence joined him at “the very bare, comfortless and isolated” farmhouse the following week. Seven months later and two months shy of his 13th birthday, Dennis was dead.

He suffered a heart attack following a brutal beating to his chest and back with a stick by his foster father, Reginald Gough. Dennis had septic ulcers on his feet and severely chapped legs. He weighed just over four stone. His stomach was empty. He had been so undernourished that he had sucked cow’s udders for milk.

Deprived of food, he “stood the night before he died, watching other people eat a meal”. Stripped naked, he was tied with rope to a bench and beaten with a stick until his legs were blue and swollen and he was unable to stand. He was then locked in a cubbyhole. Following a public outcry, Gough, who had been sentenced to six years for manslaughter, was re-sentenced receiving 10 years for murder. His wife Esther was sentenced to six months for “exposing the said child in a manner likely to cause unnecessary injury to health”.

Sir Walter Monckton’s one-man, four day inquiry opened on 10 April 1945. He found that the Goughs had been selected “without adequate inquiry being made as to their suitability” and that “there had been a serious lack of supervision by the local authority”.

Shropshire Council’s public assistance officer had informed Newport officers that he was “unable to see his way clear to arrange supervision of your cases” because Newport was paying the Goughs a higher boarding out allowance (fostering fees) than Shropshire’s rates. “Disparities of this kind had caused trouble in the past. It was not a question of saving money but of avoiding friction with foster-parents,” the inquiry said.

On 20 December 1944, a clerk from Newport, a Miss EM Edwards, was in Shropshire to discuss the payments dispute. While there she was asked to visit the boys, although the inquiry found she “had little experience to qualify her to undertake a visit to supervise the children in their foster home”. Nonetheless, she knew things were not right.

In her report she recommended the “immediate removal” of the boys and commented that she “several times impressed upon Mrs Gough the necessity of calling in a doctor for Dennis”. Neither authority responded with any urgency. In Shropshire, the report was put aside for an officer to deal with “on his return from annual leave on the 10 January” – Dennis died on 9 January.

The issues that contributed to his death – poor record-keeping and filing, unsuitable appointments, lack of partnership working, resource concerns, failing to act on warning signs, weak supervision and “a lamentable failure of communication” – were not buried with Dennis O’Neill. These failings were to feature regularly in inquiries held into the death or abuse of children in care for the next 60 years – up to and including that of eight-year-old Victoria Climbié.

Victoria’s death drew a stinging indictment from the former head of the Social Services Inspectorate, Sir William Utting, who himself had conducted two inquiries into residential care in the 1990s: “It is as if these agencies had expunged the entire history of working with children from their memories.”

Back in 1945, Monckton’s findings led to the setting up of the Committee on the Care of Children, which itself inspired the Children Act 1948. This advocated keeping children with their birth mother where possible. Indeed, with the publication, in 1952, of the first volume of John Bowlby’s influential work Attachment and Loss, the primary importance of birth families was secured.

But all of this wisdom was knocked sideways on 6 January 1973. Maria Colwell had been fostered by her aunt and uncle (Doris and Bob Cooper) for five years because her mother, Pauline, couldn’t cope with bringing up five children. Then Pauline decided she wanted Maria back. Guided by the notion of the birth mother’s rights, Maria was returned to Pauline on 22 October 1971 and moved  into the council house she shared with her future husband William Kepple on Maresfield Road, Brighton.

What was left of Maria’s young life would be characterised by neglect, cruelty and distress. At 11.30pm on Saturday 6 January 1973, Kepple came home to find the six-year-old watching television. He beat and kicked her to death. Maria suffered brain damage, a fractured rib, black eyes, extensive external bruising and internal injuries. The pathologist described her injuries as “the worst he had ever seen”. Kepple, sentenced to eight years for manslaughter, had the term reduced to four years on appeal.

The government finally conceded to set up a full public inquiry after media pressure. Being the first of its kind it unwittingly etched the blueprint for all subsequent inquiries. Indeed, inquiries became the accepted means of dealing with death and abuse.

On average about 80 children die of abuse or neglect in England and Wales every year, and there have been more than 70 inquiries since the Children Act 1948. Each time their restricted remits have focused on single cases and honed in on failure, causing many to question their efficacy. In 1975, for example, the British Association of Social Workers declared inquiries “a pointless exercise, serving mainly to scapegoat social workers”.

Crucially, each inquiry’s findings became the precursor of national or local policies designed to make sure history wasn’t repeated. But repeat it did. Indeed, repetition was a sentiment to which the 1980 Carly Taylor inquiry wearily subscribed: “Many of [the recommendations] are largely repetitious of others, it would be pointless to repeat them. We would only say that, if they had been studied and followed by those concerned at all levels in this case, it is reasonable to assume that the troubles with which we have been concerned might well not have occurred.”

The Colwell committee inquiry, chaired by Thomas Field-Fisher, QC, found poor communication and liaison between the agencies and a lack of co-ordination. Despite 50 official visits to the family from social workers, NSPCC inspectors, health visitors, police and housing officers, there was poor recording, a lack of information sharing, and a lack of any collation  of case history. Indeed, the 1979 Lester Chapman inquiry would later note a tendency “when many persons have duties in relation to one family, for responsibility to become blurred and decisions avoided, and for vital information to be lost sight of or overlooked.”

Again, in the Colwell case, warning signs were ignored. Over several visits, the NSPCC inspector recorded several instances of physical injury – such as bruising – none of these were followed up. Neighbours, concerned at Maria’s treatment, time and again complained to social services, NSPCC and police – all of whom did nothing.

Agency liaison
A lack of co-ordination and communication between agencies were also at the root of the deaths of Stephen Meurs (1975) and Heidi Koseda (1984), who both died of starvation. In the former case, the GP knew that Stephen’s mother was seriously depressed, the health visitor was never allowed to see Stephen but believed the other siblings were fine so assumed he was too, and the social worker had received complaints from family and neighbours about inadequate care.

But nobody had talked to each other. In Heidi’s case – she was found in a cupboard in a locked room – a senior NSPCC inspector failed to investigate a complaint from a neighbour (and even tried to cover it up at the inquiry). Meanwhile, the social worker’s concerns were alleviated by the mistaken belief Heidi had been seen by the health visitor, who despite calling 16 times had not actually seen the young girl. Being unable to gain access to a child was also a clear warning signal in the case of Carly Taylor: the health visitor made 23 visits to Carly’s home over 11 months gaining access to her only on 14 occasions.

Similarly, four-year-old Jasmine Beckford proved elusive to professionals. She had had spells in care but back again with her mother, Beverley Lorrington, Jasmine was battered to death by her step-father Maurice Beckford on 5 July 1984,. At the inquiry, Jasmine’s social worker said “the family obviously loved the children” but admitted only seeing Jasmine once in 10 months, believing the family’s explanations as to why she was unavailable. In fact, Jasmine had been locked in a small bedroom with body-building weights tied to her broken legs to stop her moving. Emaciated and deformed, she weighed just 23 pounds. She had 40 injuries to her face and body – her ribs were also broken and she had ulcers, burns and cuts to her leg.

While recommending improved cooperation between social services and health, the Beckford inquiry also criticised the social workers for “regarding the parents of children in care as the clients rather than the children in their own right”.

That same year, 21-month-old Tyra Henry was murdered by her father Andrew Neil after white social workers from Lambeth Council, south London, were found to lack the confidence to challenge the family because they were black. Neil had already been convicted of cruelty to his son Tyrone whose injuries – including fractures of thighs and skull, retinal haemorrhages, and brain damage causing fits – had left the boy blind and with a learning difficulty. On Neil’s release from prison in October 1983 professionals were too ready to believe Tyra’s mother, Claudette, that she had finished with him: she had not.

Physical assault
He went on to carry out numerous physical attacks on Tyra. On 29 August 1984, Neil hurled Tyra to the bed “with such violence that she hit her head on the headboard” causing a skull fracture. He later attacked her again “biting, scratching and striking her repeatedly”. She died the next day. The pathologist found “something like 50 bite marks” on her body. Again the inquiry concluded the problems lay with inadequate liaison (this time between housing and social services), training, resources, supervision and experience, and a failure to respond to the warning signs.

In several cases (including Godfrey, Piazzini, Howlett, Clarke and Chapman) the parent or parent figure had asked for children to be removed. The health visitor had asked the GP to attend Maria Mehmedagi as she feared a non-accidental injury. The GP refused. Not only were parents’ views ignored but children were regularly not listened to.

For example, in the case of nine-year-old Wayne Brewer, referring to his injuries, told the social worker, health visitor and GP that “Daddy did it”. Similarly, Darryn Clarke, aged four, told a friend of his mother’s that “Charlie had done it” contradicting his mother’s story that he had fallen downstairs – he had been abused by his mother’s partner Charles Courtney. Also, Paul Brown, six, told nurses that “daddy hits mummy, also daddy made sores on left hand with matches”.

Undoubtedly, such inquiries have had an impact. For example, the numbers placed on child protection registers or subject to place of safety orders rose markedly from 7,622 in 1985 to 29,766 by 1987 and 41,200 by 1989.

But some things remained the same. The Victoria Climbié inquiry heard how social worker Lisa Arthurworrey complained “about how she was set up” by Victoria’s great-aunt Marie-Thérèse Kouao. This, said the inquiry, carried with it uncomfortable reminders of the 1976 case of Neil Howlett, which found: “Parents are quite capable of deceit, and of attempts to manipulate social workers. Parents often try to play off one welfare agency against another to exploit lack of communication.”

More recently, in 2002, the inquiry into two-year-old Ainlee Labonte, who was starved and tortured to death by her parents, Leanne Labonte and Dennis Henry in Plaistow, east London, found that the health and social workers were too scared of the parents to act.

On 17 May 2000 in Dumfries, Scotland, three-year-old Kennedy McFarlane died after a blow from her mother’s boyfriend sent her crashing into the leg of a bed. The inquiry led by consultant paediatrician Dr Helen Hammond concluded that although Kennedy’s “violent death could not have been accurately predicted it could have been prevented”. It recommended, once again, better partnership working between agencies, and improvements in communication, staff supervision, record-keeping and documentation.

Despite most, if not all, cases being similarly avoidable, a general analysis of the inquiries does not throw up a picture of gross errors or catastrophic failures by individuals, but rather a succession of errors, minor inefficiencies and misjudgements by several agencies. We have quite simply too often got the basics wrong.

Lord Laming said at the time of the Climbié inquiry that Victoria’s death would mark a “turning point in ensuring proper protection of children in this country”.

History, however, tells us not to be so sure. 

How can social workers avoid being deceived by abusive parents/carers of children? Have your say on our Discussion Forum 

Related article
A chronology of selected inquiries
Seven steps to better protection

Contact the author
Graham Hopkins

This article appeared in the 11th January issue under the headline "Fatal failings"