Restructure led to ‘early closure’ of case where girl was abused, review finds

The review also said the council's special guardianship assessment was too optimistic after she was abused in the placement

A restructure of a council’s children’s services led to the “early closure” of a case where a child was sexually abused, a serious case review has found.

The review into how agencies in Devon responded to ‘Bonnie’, a two-year-old girl who was abused while in a special guardianship placement, said that a restructure in Devon children’s services created pressure to close cases. This meant Bonnie’s case was closed to children’s social care at a “crucial” time of monitoring and review.

The closure, six months after the special guardianship order (SGO) was granted, created a reliance upon children’s centres and other relatives to monitor the child’s development. The review said this fell short of meeting the level of multi-agency co-ordination and supervision required by the SGO.

Crucial time

Bonnie entered a SGO with her grandmother in February 2013. A 12 month supervision order was also made to Devon council.

The SGO was made on the understanding the child’s grandfather, who had a history of alleged sexual abuse towards his own children and domestic violence towards the grandmother, should have no contact. However, 18 months after the SGO was made, social services undertook a section 47 child protection investigation over concerns the grandfather was living in the home.

The review found the decision to close the case was “crucial” to subsequent events, where the grandfather made fresh contact with the family and the grandmother broke the conditions of the SGO.

Responding to the review findings, the council said that during 2013 it was “struggling to cope with an enormous increase in referrals” and had since taken “significant” steps to improve safeguarding practices.


The special guardianship assessment did not adequately factor in historical abuse within the family, and relied on evidence that related to “very immediate and current conditions and certainly not past events”, the review found.

The assessment carried “a significant degree of optimism given the family history” and should have reflected “far higher” risks, it added.

Suspicions Bonnie had been sexually abused were first raised on a Friday, when a social worker spotted soreness not attributable to nappy rash. But this was not acted on because of a “lack of clarity of the procedure for a forensic examination of a child where there is concern about sexual abuse”, the review said.

It found professionals lacked confidence to undertake assessments, or take action, where there was concern about child sexual abuse, adding: “In this case, the reliance upon forensic medical examination to identify sexual abuse, and the reluctance to commission the examination, resulted in a significant delay to due process”.

The following Wednesday, Bonnie was found to have “significant abrasions and bruising”.

An examination was commissioned which found “clear evidence of significant sexual abuse and physical harm”. She was placed in temporary care with her great grandparents, and made subject to a placement order for adoption. It was unclear who committed the sexual abuse.

“It remains unknown but likely on the basis of subsequent events that had Bonnie been examined on the [Friday] she would have been removed from the family home and related danger at that stage,” the review said.

‘A rule of optimism’

The review recommended that the criteria for referring sexual abuse should be clear for all agencies and practitioners, and this should include a known pathway for professional consultation and advice.

It added that impact assessments should be an essential part of strategic planning before a system change in safeguarding services, and social workers should not “submit to a rule of optimism” when assessing placements.

Council response in full

A Devon council spokesperson said: “The ‘Bonnie’ case was tremendously complex, holding lessons for all professionals and organisations concerned with children’s safeguarding.

“In 2013 we were struggling to cope with an enormous increase in referrals, but we have since taken significant steps to improve our safeguarding practice and have made new management arrangements.

“Recognising that the law prioritises placements of vulnerable children within their families wherever safe and appropriate to do so, we’ve strengthened risk assessments and the way we look at and understand family histories.

“We’ve improved the way we work and have developed a SGO team who are involved in risk assessments and have ongoing support roles. We’ve built stronger links with the domestic abuse service and have made significant progress in identifying risks related to domestic abuse.

“Multi-agency support arrangements are now more effective. Support is better coordinated and there are now more checks and balances which focus on the child as paramount.

“All cases where child sexual abuse is an element or there are known sex offenders in a family’s network have been reviewed and addressed on a multi-agency basis.”


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