SCR into child’s death finds social work and mental health failings

The death of a four-year-old girl suffocated by her mentally ill mother could not have been predicted, but there were serious failings by numerous agencies, including social workers.

That was the conclusion of a serious case review, published today, into the death of Kaiya Blake in September 2011. Kaiya was known to Manchester social care and was the subject of a child protection plan for the 10 months leading up to her death.

Her mother, Chantelle Blake, pleaded guilty to manslaughter on the grounds of diminished responsibility at Manchester Crown Court last November. It was accepted she suffers from paranoid schizophrenia.

‘Insufficient focus on risk to the child’

The serious case review (SCR) found serious failings by mental health agencies after repeated mental health assessments concluded there no concerns. However, it also found social workers – who received many referrals about Kaiya – had focused too much on obtaining a medical diagnosis and not enough on the presenting evidence of risk to the child.

“The fact that assessments concluded that no mental illness was present was treated as an outcome to the concerns rather than an indicator as part of a more holistic assessment. [Social workers] appeared to remain simply puzzled by the lack of any formal diagnosis and how they could continue from that point,” the report stated.

Hostile and aggressive behaviour

Blake was a heavy cannabis user who behaved in a hostile and aggressive manner to all professionals, her own family and other parents and children at the children’s centre she attended. She also sometimes reported hallucinations and severe paranoia.

She was obsessed with the risk of sexual harm to her daughter, twice stripping her daughter after she returned from emergency foster care to look for signs of sexual abuse.

The SCR said no investigation was made of whether this behaviour stemmed from sexual abuse in the mother’s own childhood.

Despite reports and referrals detailing incidents of physical and emotional abuse, social workers returned Kaiya to her mother the next day, subject to a child protection plan due to “neglect”.

Mother left confused by professionals’ concerns

This meant the mother was confused by professionals’ concerns, because it appeared clear that her daughter was physically well-cared for and meeting developmental milestones.

There were also 10 scheduled case conferences, but six were cancelled and others had poor attendance. The report criticised the child protection plan as suffering from a lack of focus. It also highlighted that the child had not been seen on her own at any time in the process.

Many of the problems stemmed from inadequate social care assessments that lacked rigour, or any investigation into what life was like for the child, the SCR concluded. As a result, social care closed the case numerous times with little justification.

Recommendations for social workers

The review recommended the case be used as an instructive case scenario against which to test out the developing single assessment used in Manchester following the Munro Review.

It also recommended that social workers should be prepared to challenge other professionals, including those in the medical profession, and an analysis be carried out into why Manchester has a lower than average number of child protection plans focusing on risk of sexual abuse.

Picture credit: Bruce Adams/Daily Mail/Rex Features

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