Council’s use of special guardianship order criticised in serious case review

Agencies allowed a desire for a special guardianship placement to be successful obstruct child protection processes

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A decision to place two vulnerable children with special guardians they did not know, and who later went on to abuse them, has been criticised by a serious case review for being based on optimism instead of evidence.

Two children – both under five and with various physical and learning disabilities – were placed with the couple and abused in the year following guardianship and supervision orders being made.

The couple, Ms L and Mr K, had been together three years and Ms L was a distant relative to the children. Both were said to be involved in supporting the birth parents but did not know the children personally.

‘Grotesque abuse’

The children had been removed from the care of their parents, who had learning disabilities, in 2012 after Oxfordshire council children’s services said they were unable to continue caring for the oldest, Child A.

The youngest, Child B, was removed at birth and they both lived in separate foster care placements until Child B was placed with the paternal grandmother. She wanted to continue to care for Child B, but the local authority decided she was unable to provide permanent long-term care due to concerns about the care of her own son (Child B’s father), agency involvement with her care of Child B’s aunt and her use of alcohol and a violent partner living in the home.

The children were placed with Ms L and Mr K in April 2014, until the abuse was discovered in March 2015. Mr K was convicted of physically abusing both children and of raping one.

The serious case review said the “grotesque” abuse of the children could not have been predicted but found serious flaws in the assessment of the two guardians.

“Neither of the special guardians had any experience of parenting, nor any experience of looking after children with substantial disabilities and disadvantages. They almost drifted into the children’s lives yet became their legal parents,” the review said.


The couple were first mentioned as possible guardians during a family group conference and the review stated that this may have given the idea a degree of legitimacy that it would not have had had they come forward in different circumstances.

“Once an idea like that is mooted it can take on its own momentum,” the SCR author commented.

In 2015, the government conducted a review of special guardianship which identified concerns over “rushed or poor quality assessments”, “potentially risky placements” and “inadequate support for special guardians”.

The serious case review said the national flaws identified by the government review featured in this case.

During the placement, staff at the children’s nursery reported two incidents of the children arriving with facial bruising to social workers, however neither incident was followed-up.

“Overall the desire for the placement to be successful inappropriately affected child protection processes,” the review said.

It said there was “unevidenced optimism” that various arrangements made for the children within their family would meet their long-term needs.

The SCR said “over optimistic” and “reactive” decisions had dominated the care-planning work in the case including a decision to close child protection procedures for the older child in 2011. Only a year later, when the second child was born, the authority decided the level of care the parents provided was inadequate.

However, it concluded that agencies and individuals worked together with “real commitment”.


The council’s director for children’s services, Lucy Butler, said the council accepted the findings and had made improvements in line with its recommendations.

“We are continuing to provide specialist support for Child A and B as they attempt to rebuild their young lives. Despite their terrible ordeal, they are happy and settled in their current foster care arrangement. They also continue to live together.”

Butler also praised the “great compassion” of professional who worked with the children, which was acknowledged in the review.

Independent Chairman of the Oxfordshire Safeguarding Children Board Paul Burnett said it was a “distressing case” and there was no evidence that what happened could have been predicted.

“The review recognises that children’s social workers and other professionals demonstrated great compassion and commitment in promoting the best interests of the children. It also raises concerns which have led to recommendations for improving care planning processes and highlighting the particular vulnerability to abuse, of children with disabilities and special needs.”

Burnett added: “Significantly, the government had begun a review of the use of Special Guardianship Orders at the time of this case, and guidance on when and how such care arrangements should be used in Oxfordshire has been strengthened following national changes.”

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One Response to Council’s use of special guardianship order criticised in serious case review

  1. Finola Moss March 10, 2017 at 10:08 am #

    SCRs are rare and there is a lot of undiscovered or not disclosed or acted upon abuse.

    Might all this be a means of destroying Guardianship which has recently become more popular and does not feed the profitable fostering and adoption industries.?.

    Why were these children removed in the first place, we have more removals from parents deemed to have ‘learning disabilities’, than anywhere else in the world, see research into comparisons with Australia conducted by Sheffield University.

    These children have suffered because of this removal and this is what needs to be remedied.