Serious case review into girl’s death finds ‘fragmented’ family support services

Seven-year-old Shanay Walker died from a brain injury in July 2014 while under a special guardianship order

Shanay Walker died aged 7. Picture: Nottinghamshire Police

A serious case review has found support for a family was “fragmented” in the lead up to the death of a seven-year-old girl.

Shanay Walker died from a brain injury in July 2014, two years after being placed into her aunt Kay-Ann Morris’s care under a special guardianship order. Morris and Shanay’s paternal grandmother, Juanila Smikle, were jailed for child cruelty in 2015.

Shanay endured a chaotic early life and had mild learning disabilities and kidney problems. She and her sibling were removed from their mother, Leanne Walker, in the wake of Walker suffering from post-natal depression and struggling to care for them.

The serious case review found a ‘light touch’ family assessment order (FAO) imposed after Shanay was placed with Morris meant no coherent plan for her wellbeing was implemented. Consequently, issues noted by various professionals that might have served as early warnings, including bruising and question marks over Morris’s care for her niece, were not shared.

Separated teams

At the time of Shanay’s placement with her aunt, Nottingham council had formed a separate family support team of specialist agency staff.

“This decision was taken to enhance the family support process, but had the opposite effect because the team became separate from mainstream work and planning,” the review found.

Shanay’s case was handed over to a family support worker from a social worker eight weeks after she moved in with her aunt.

Over the following two years there were numerous incidents of bruising, burns, other injuries and behavioural problems noted by Shanay’s school. While on many occasions these were recorded as having been passed on to children’s services, corresponding evidence to support this was often missing and the review concluded that information had not always been shared as it should have been under safeguarding protocols.

While the family support worker did discuss injuries to Shanay with her school’s safeguarding lead and agreed to share incidents in future, “the meaning of this was not explored and the FSW did not ask about what records were held”.

At the same time Morris’s “harsh” parenting style, which included physical disciplining, was noted. In spite of this, professionals remained focused on her version of events – in which Shanay was self-harming, “testing” her and deliberately bed-wetting – and mistakenly saw the problem they were dealing with as a behavioural one, the review found.

Confusion around changes to safeguarding arrangements at Shanay’s school exacerbated the issue and support from CAMHS was pursued rather than exploring child protection concerns.

Despite continued reports of “inappropriate disciplinary approaches” by Morris, the school was informed in June 2014, one month before Shanay’s death, that her case would be closed by children’s services. “Once again [her] needs were lost through entrenched, adult-focused views,” the serious case review said.

‘Manipulation and deception’

Professionals, the review noted, were “manipulated and deceived” by Morris throughout the two years Shanay lived with her. Recordings of meetings taken by Morris and subsequently examined revealed her dominance of proceedings.

“The level of cruelty was glimpsed, but not fully known,” the review found. It highlighted “the absence in this case, caused in part by the granting of an FAO, of routine processes such as ongoing assessments, plans which make clear the nature of a child’s needs and good multi-agency working arrangements, effective reviewing arrangements, clarity of task and role [and] an awareness that parents/carers who are abusing children create divisions and diversions so they are not found out”.

The family support worker was found to have “colluded” with Morris, taking her side against the school in order to maintain a relationship. “This must never happen,” the review concluded.

Among a series of recommendations, the review said that Nottingham City Safeguarding Children Board (NCSCB) should:

  • Seek to better understand the implications of parental mental health problems and how better to implement support;
  • Highlight the importance of recognising and understanding early childhood trauma, including ensuring that this is communicated to partner agencies;
  • Update its practice guidance around young children and self-harm;
  • Review guidance for all professionals regarding the assessment of potential non-accidental injury and ensure it is compliant with NICE guidelines regarding child maltreatment.

Commenting on the serious case review, NCSCB chair Chris Cook said: “While professionals had Shanay’s wellbeing at heart, with the benefit of hindsight it is clear they could have displayed more professional curiosity about issues and incidents which emerged.”

Cook added that the NCSCB had made recommendations to address issues around identifying and reacting to potential self-harm and non-accidental injuries among children, responding appropriately to other health issues and ensuring that the role of schools in safeguarding children is recognised and reflected in multi-agency practice.

“We are satisfied that appropriate changes are under way or have been implemented, and that all agencies would now be more focused on how their collective actions impact and benefit the child,” he said.

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8 Responses to Serious case review into girl’s death finds ‘fragmented’ family support services

  1. Peter Endersby April 20, 2017 at 7:44 am #

    These SCRS are a waste of money and do nothing to prevent the same failings killing other children. It still is baffling why services supporting children are so inconsistent in their approaches. The myth that local issues prohibit a one size fits all approach are undermined by these SCRs which consistently see the same failings despite local variations in service.

    • Mrs champion April 24, 2017 at 9:50 pm #

      And it is once again Nottingham social services in the spotlight for failing to safeguard the wellbeing of a vulnerable child,resulting in her death…the chair never even said she was sorry she died,nothing..

  2. Rosaline April 20, 2017 at 2:01 pm #

    Leadership was lost by all involved, lessons cannot continue to be learned, as a result of children dying in such cruel and inhumane ways.

  3. Pauline McCarthy April 20, 2017 at 4:12 pm #

    The issue of FSW’s befriending parents and maintaining professional boundaries is an un-assesed risk factor in itself that needs further investigation. This is particularly relevant with charming manipulative parents and inexperienced staff. There is a suttle difference between compliance and manipulation, major training & supervision issue!

  4. lucy April 20, 2017 at 9:09 pm #

    The key here was a superficial assessment was done probably due to chronic workload and lack of support issues, when the obvious was overlooked – an unsuitable and domineering bully of a woman was allowed to care for a vulnerable child (probably due to wanting the financial payments) and a child has now died – tragic. When will central government wake up and fund more social workers to protect children?

  5. Rachel williams April 22, 2017 at 8:44 pm #

    I sat in on the inquest of this case and the coroners findings vary substantially to the SCR findings. The coroners narrative verdict was based on first hand evidence under oath questioning whereas the SCR relied on individual agency reports and ‘chats’ with individuals. Get the coroners report and see for yourself!

  6. Paul Owen April 24, 2017 at 11:42 am #

    Significant differences indeed!

    Main concerns raised everywhere other than the SCR was that school didn’t follow the recognised guidelines, report what Shanay said to teaching staff to the social work staff or police and appear to have altered some documents, the poor initial assessment of the family by the allocated social worker and the missed opportunity at hospital etc. The Initial Assessment should have been signed of by management and any shortcomings recognised.

    I can’t see any reference to an FSW colluding with the family other than in the SCR and would remind Pauline that FSW have been around for many years and without them holding cases qualified worker would have significantly more work that they do at the moment. Also there should be a proper supervision system in place and the injuries apparently reported should have led to a Strategy Meeting orchestrated by the manager. In my area the SGO Team does not have FSW’s holding cases and all team members are qualified SWs with a family aide to help with contact etc.

    It is somewhat worrying that Shanay’s case was to close if social care were aware of all the concerns raised! This would need to be agreed by management.

    It does also raise the question over the fragmentation of social care into isolated teams.

  7. Eileen Jeffries May 4, 2017 at 10:13 am #

    There are many cases where secial guardianship orders do work. They work in the sense that the child can remain with family who are prepared to take responsibility for the child, they also, support the family with very often desperately needed finances in order to continue to support the child. nIt is not the SGo that isnot working, it is the contin7uous dwindling resouces of local Children’s Service, the many changes in Social Workers assigned to cases due to then leaving the profession and/or moving on to other LA’s. When will lessons ever be learned by both government, in continuously cutting services and privatising services, and, importantly, Children Services, who do not seem to communicate with each other and other agencies involved. Here we ar5e again, Poor if non exisitent communication, and sadly again, another child has lost their life, because people do not communicate!!