The lessons to be learnt from three recent high profile serious case reviews

In less than a month two serious case reviews and a criminal trial have concluded, which all involved a mother killing one of her children, despite agencies' involvement in their life.

Child on a swing
Photo: Gary Brigden

In less than a month two high profile serious case reviews and a criminal trial have concluded, which all involved a mother killing one of her children, despite the involvement of several agencies in the child’s life.

The first was the case of Daniel Pelka, a four-year-old living in Coventry who was singled out for abuse and neglect by his mother and her partner until his death from a blow to the head in March 2012.

The second was the case of Keanu Williams, a toddler living in Birmingham who died with 37 separate injuries on his body, inflicted by his mother in early 2011.

The last was the conviction of Amanda Hutton in Bradford Crown Court for the severe neglect and manslaughter of her four-year-old son Hamzah Khan. The boy’s mummified remains were found in his cot in September 2011, two years after his death in the squalid flat where other children were living.

Nushra Mansuri, professional officer with the British Association of Social Workers, is worried about the cumulative impact. “It is unprecedented to have so many cases where so many horrific details all come out at the same time,” she said. “It leads to the general public feeling that more and more of these cases are happening and the authorities are failing. But it’s not true. If you look at the actual figures then the number of deaths due to neglect and abuse are falling, and of those only a tiny proportion are known to social services.”

In all three cases the mothers were actively deceitful, often antagonistic and convincing liars when explaining away injuries or keeping professionals away from their door. Both serious case reviews identified that professionals had succumbed to the ‘rule of optimism’.

While it could be argued that dealing with antagonistic and deceitful parents is par for the course in child protection, challenging the rule of optimism is complicated, according to Dave Tucker, head of policy at the NSPCC.

“Social workers and other professionals are placed in the difficult position of having to maintain a healthy skepticism about what parents are saying, despite knowing it will affect what’s called the ‘therapeutic bond’ and the chance to turn things around in a family”.

But Tucker says research currently being undertaken to examine the reactions of different social workers to parental information and presentations could help. “It could provide a tool for supervisors to identify when they need to challenge a social worker on their acceptance of explanations or when to ask if they are being too eager to take a child into care”

Another key issue running through both serious case reviews (SCRs) were problems associated with multi-agency working. In both cases professionals often had concerns running in parallel to each other but never seemed able to join them up together which, according to the hindsight of a SCR, would have flagged up serious issues.

While hardly a new issue, it seems depressing that despite the concerted attention given to multi-agency working since Victoria Climbie’s death, issues still remain.

Tucker is hopeful that more multi-agency safeguarding hubs (MASH) will provide a solution. But Mansuri points out that not every council has a MASH or plans to have one. And even in areas where they do exist there is anecdotal evidence that because of the massive public sector cuts, several agencies are cutting their funding to them.

This, she argues, shows that funding cuts and child protection cannot be separated. As cuts deepen so do the risks of children dying from abuse. “For example in Birmingham I believe there are 100 vacancies out of a total of 450 social workers and of the existing workforce 50% of them are agency staff. Social workers are working 20 hour days and still not getting on top of their caseloads. I could be the best social worker in the world and I still would not be able to do good social work in those conditions.”

Kate Mulley, head of policy and research for Action for Children, says in both SCRs many professionals seemed to feel that making a referral to social care was enough to fulfil their duty. “But as budget cuts bite and the number of referrals increase it becomes increasingly difficult for social workers to sift through the referrals and prioritise them properly,” Mulley says.

She would like to see more multi-agency partners empowered to deal with neglect when it is first suspected, pointing out both SCRs involved suspected neglect and physical abuse. Dealing with the neglect early on could perhaps have prevented, or at least identified, the physical abuse, she argues. “We have this tendency to adopt a “wait and see” attitude, waiting for a trigger incident before taking action when we suspect neglect. We need to empower everybody to do something.”

But Amanda Thomas, child protection lead at the Royal College of Paediatrics and Child Health, says that’s unrealistic for many doctors. “We are usually working during a full clinic and we don’t have time to ring around GPs or health visitor clinics to chase up concerns. In my view that is the purpose of multi-agency working- we feed our concerns to a central point which is usually a social worker. Paediatricians are often working in isolation without knowledge of what else is happening within the system and often reliant upon parents to give us the family history.”

While she agrees some paediatricians could be clearer in their communications to social workers who find “vague concerns” difficult to act upon or prioritise, she also believes an electronic health record would help join up the dots across multiple, independent health organisations at least.

Some believe that embedding social workers within other universal services is the only way to make multi-agency working effective in a time of austerity.

For example the Child Exploitation and Online Protection agency has embedded social workers in each team while councils such as Worcestershire have started embedding social workers in schools where there are high deprivation rates or large numbers of referrals.

As Tucker points out: “We’ve thrown money at this issue in the past and it didn’t really result in any significant change. It has to be about better targeting of resources at the front-line.”

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One Response to The lessons to be learnt from three recent high profile serious case reviews

  1. Julie Wilkes October 10, 2013 at 6:19 pm #

    This all sounds plausible, and can reasonably be inferred from the scrs, but we still need to improve the evidence that scrs provide, by including the perspectives of the staff at the time, as recommended by the scie model. This would give a window into their thinking and help clarify why they saw things the way they did. Reviews remain frustratingly opaque which is how they give rise to the same old same old stories.