Agencies across Doncaster were criticised for failing to protect two children who were later murdered by their fathers, in serious case reviews published today.
The reviews were issued with the south Yorkshire council’s children’s services operating under government scrutiny, after it was judged as inadequate by Ofsted last year.
Agencies missed three key opportunities to protect a 16-month old child – named in the press as Amy Howson – according to one of the SCRs.
Amy died in December 2007 from multiple injuries including bruising to her forehead, face, neck and “thin, poorly nourished” body. Her father pleaded guilty to her murder in October last year.
Doncaster children’s services’ duty and assessment team failed to carry out an initial assessment on Amy after South Yorkshire Police referred on domestic violence concerns in late January 2007, the SCR found. This would have led to a child protection plan being produced for her and her older brother, known as Child C.
In mid-May 2007, neither Doncaster’s youth inclusion support service nor Child C’s school recognised or responded to concerns about the father’s “aggressive” behaviour in the home, and failed to inform the duty and assessment team.
And a month before Amy died, Doncaster Primary Care Trust’s health visiting services’ “narrow focus” on Amy’s physical health meant they failed to see the need for a more “challenging and thorough assessment”.
Murder not predictable
But the review found that there was “no evidence” to suggest the father had the potential to murder his daughter, despite evidence indicating that he was a “violent and aggressive individual and a risk to children”.
It said Amy’s death was “not predictable or preventable” but concluded that some agencies had “palpably failed” to safeguard her and her brother.
Alfie Goddard SCR
The second SCR, into the death of an 11-week old boy, also found failings by Doncaster agencies.
The child, named in the press as Alfie Goddard, died in March last year from a head injury after being violently shaken by his father who was trying to get him to sleep.
He pleaded guilty to his son’s murder and was jailed for life. The child’s mother also pleaded guilty to perverting the course of justice and was given a 12-month suspended sentence.
Children were vulnerable
The review by Doncaster Safeguarding Children Board found there were “numerous indicators” to show Alfie and his sibling were vulnerable and the family was in need, but ten agencies, including Doncaster PCT and children’s social care, had failed to take these account.
Agencies “acted in isolation” and inter-agency working and communication were “largely inadequate”, the SCR found. Staff shortages in children’s social care meant social workers failed to carry out an “acceptable” duty and assessment service when contacted about the family.
Common Assessment Framework
No common assessment framework was completed on either child “despite several occasions when it would have been appropriate to have done so.” The review found the CAF had not been “embedded in practice” in Doncaster and was still not being used on a regular basis.
The Goddard review made 37 recommendations including ensuring the use of the CAF and staff training in assessments and referrals. The Howson review made six key recommendations including making the children’s duty and assessment team “effective” within six months.
Doncaster’s interim director of children’s services, Gareth Williams, admitted there were “serious problems” in appointing permanent staff to the duty and assessment team, but said plans were in place to rectify this. He also said action was also being taken to implement the common assessment framework.
Williams confirmed that many of the issues identified in the Goddard SCR were included in a recent improvement plan for children’s services.
In March, children’s secretary Ed Balls ordered Doncaster Council to appoint a new senior management team for children’s services and appointed an improvement board to monitor progress, on the back of Ofsted’s verdict and a further probe by government officials.