Rapid turnover of social workers contributed to the breakdown of a council’s understanding of the circumstances facing a fostered child who died, a serious case review has found.
The 17-year-old boy, referred to as E, died in December last year after having hanged himself. A coroner returned an open verdict on his death after concluding there was insufficient evidence to conclude whether he died by accident or suicide.
The boy had been in the foster care of family members since the age of three and his “status as a child in care increasingly troubled him” as he got older. In the weeks before his death he had become “terrified” by threats after he assaulted a boy he blamed for robbing his carer’s house.
The review concluded his death could not have been predicted or prevented, but also highlighted the difficulties of working with long-term family and friend placements where a local authority, in this case Brighton and Hove council, still possessed a full care order.
In the two years prior to his death, the boy experienced four changes of social worker, none of whom had seen him more than five times. Prior to this, he had settled relationships with professionals, the review said.
“Inevitably this led to difficulties for each social worker in being able to establish a relationship with him, with E becoming increasingly elusive.”
His carers said he “bitterly” complained about social work changes, and said: “‘Why am I going to confide in someone I have only known for five minutes?’”
Problems were also caused when the boy was moved to a 16+ team. This coincided with an Ofsted mandate that children in care had a qualified social worker allocated to them, meaning he lost the long-term support of his social work support officer, and his Independent Reviewing Officer of five years also changed.
“This meant that some of the organisation’s continuity of knowledge and understanding of E and his foster family was broken,” the review said.
It was not clear how the impact of these changes in professional was considered by the authority. Both had been involved with the family for a large part of his childhood, and the review authors felt an assessment on the likely impact of these changes should have been undertaken.
Different from practice
The length of the placement meant the local authority “inherited” a situation where the requirements on his carers “were very different from current practice”, the review said.
“At that time, there were far fewer formal expectations of [family and friends] carers, and the rigorous requirements which are now in place for all foster carers did not apply (e.g., levels of annual training, unannounced visits, etc).
“Thus, there was an ‘inherited’ pattern for the [local authority] of working with this family, formed by earlier decisions and relationships with the carers.”
The boy had growing anti-social behaviour problems throughout his teen years, and Sussex Police were criticised for poor record keeping of their contacts with him.
After receiving the threats in the weeks before his death he became obsessed with leaving the area. He was close to his 18th birthday, so the authority felt he would clearly be able to ‘vote with his feet’.
“What is clear is that children’s social work services’ position moved in a short space of time,” the report said. After originally feeling he shouldn’t leave the local authority area, “the social work response became reactive”.
“Notwithstanding his age, the regulations regarding placement of a looked-after child still applied, and still required the [local authority] to act as his corporate parent, in line with these regulations.”
The approval of a senior manager for an ‘unregulated’ placement was not sought, despite it being necessary.
The review concluded that the case had shown the issues of working long-term with a child in the care of family members, but who remained under a full care order to the local authority, and whose early experiences had not been fully resolved.
It found “inconsistent recording” in children’s social work services, had made it difficult for professionals to “analyse the facts and context of a child’s situation, and to make the most appropriate decisions and plans”.
It also identified a pattern of focusing on the primary carer for a child in care, and difficulty in children’s services for accessing the various sources of a child’s past records.
Graham Bartlett, chair of Brighton and Hove safeguarding children board, said the “extremely sad case” showcased how the child’s placement led to a “blurring of boundaries with regard to decision making”.
“This is a very complex area, and there is a lack of guidance both nationally and locally on balancing these responsibilities. We are therefore calling on the council to develop clearer guidance for its staff and for their Family and Friends carers.”
“There are recurring themes in the review around poor record keeping by the agencies involved, the sharing of information among the professionals involved, and communication between the agencies,” Bartlett said.
“We acknowledge that much has been done to rectify the issues highlighted in the review and the LSCB will be evaluating the impact of these changes, and those that follow from our proposals, to enhance the safeguarding of children and young people in the city.”