Flawed assessments and decision-making saw an 18-month-old girl placed under the care of a special guardian who went on to assault and murder her, a serious case review has found.
Keegan Downer, whose birth name was Shi-Anne, was killed by Kandyce Downer eight months after Birmingham council made the special guardianship order (SGO). Keegan suffered over 150 injuries during her time in Kandyce’s care and died in September 2015.
The review found Keegan’s death could not have been predicted but the assaults against her may have been prevented if the placement had been better supervised. Following the order, Keegan’s only contact with agencies was one visit from a health visitor. The review said she had become “almost invisible to professionals” after the SGO was made.
Impact of case law
The report found Birmingham council had prioritised SGOs over adoption “irrespective of the circumstances of the child”. This was due to the impact of the Re B and Re B-S court cases, which were widely perceived to have raised the bar for adoption orders, it found.
Assessments relating to Keegan’s care, including an independent social work agency’s positive special guardianship assessment of Kandyce, were “flawed and incomplete”, the report found. In hindsight Keegan should “never have been placed” with Kandyce as both child and carer failed to meet the criteria for an SGO, it concluded.
Other findings from the review include:
- The quality of the SGO assessment was “striking in its superficiality” compared to adoption placement assessments.
- Social services wrote up the case for closure on the day the SGO was granted which showcased the difference in support between other permanence arrangements.
- It was “unclear” why after the SGO was made why there were no further visits from social services, despite the final care plan suggesting three visits in six weeks before closure.
- Five older siblings had been removed from Keegan’s mother, who told the review author that court reports for Keegan’s care proceedings were copied “word for word” from when her last daughter was taken into care.
- Keegan’s mother said concerns she raised over family members looking after Keegan were ignored.
- The case was heard by Lay Justices and Magistrates who may have been “less likely” to challenge council recommendations than a judge.
- There was no flag on Keegan and Kandyce’s medical notes to alert GPs that they were effectively an adopted child and mother.
- The first time Primary Care became aware of the SGO was when Kandyce was diagnosed with severe hypertension. This may have distracted the nurse and GP from exploring the SGO and then following it up.
- There was no consideration of how past experiences may have affected Kandyce’s parenting, included a previous history of stress, two historical episodes of abuse and a new partner and pregnancy that didn’t appear to be planned.
- Close supervision and proper management was “not always evident” during the case.
Penny Thompson, independent chair of the Birmingham Safeguarding Children Board, expressed “deepest sympathies” to Keegan’s birth family and foster family who had previously care for her.
“The independent serious case review concluded that while Shi-Anne’s death could not have been predicted, the assaults inflicted on Shi-Anne might have been prevented by more professional involvement and supervision of Kandyce Downer and her children, or indeed by an alternative plan for her life altogether, via adoption.”
She said the case reflected “group think” where the use of SGOs was seen as the “right thing to do” at the time.
“There was a superficial assessment by an external agency commissioned by the city council; little challenge on behalf of Shi-Anne and her lifelong interests; poor information exchange; insufficient discussion between involved agencies, and too much focus on Kandyce Downer’s wants rather than the child’s needs,” she added.
“As a result of this and other cases, national guidance on the use of special guardianship orders has been altered to be more robust, and in Birmingham practice and management has fundamentally changed.”