A serious case review by Luton Safeguarding Children Board into a 13-month-old boy’s death has renewed concerns over how children are kept safe when they move between local authority areas, and over social workers’ understanding of risk relating to violence between adults.
Noah Serra-Morrison was killed in November 2015 by his mother Ronnie Tayler-Morrison’s violent partner, Hardeep Hunjan. He died weeks after the mother and child, who were evicted from a West London tenancy, were offered accommodation in Luton. Hunjan had been staying in Hull after being bailed on condition of not coming inside the M25, in the wake of an assault on one of Tayler-Morrison’s neighbours.
The case underlined issues flagged by the 2015 ‘Sofia’ case review around information transfer when families move between boroughs, the investigation found. It found documents sent from an Ealing council social worker to Luton’s rapid intervention and assessment team (RIAT) “did not make it easy” to identify Hunjan as a primary source of risk.
The RIAT was also experiencing high caseloads at the time of the referral, with “a strong emphasis on completing work in a timely way which meant workers would not always be able to examine closely underlying concerns”. The family’s case was deemed not to meet the local child in need threshold, so was passed onto Luton’s early help service.
‘No safeguarding concerns’
Social workers’ knowledge of Noah and his mother dated to before his birth. Hammersmith council’s children’s services first offered support to Tayler-Morrison via a child in need plan – which was declined – but identified no safeguarding issues, an assessment the review described as “sound”.
On 12 June 2015 Noah’s father, from whom Tayler-Morrison was now separated, tried to push her down a flight of stairs. A social worker with Ealing council, where the family then lived, was allocated to assess risks. But no social work intervention took place until 10 July, with Ealing’s multi-agency safeguarding hub (MASH) initially assigning a domestic violence worker.
The case review found that the incident should have triggered an immediate social work assessment. “This [decision] reflects a lack of awareness of the increased risk of physical harm to young children where there is domestic violence,” it said.
Ealing’s social worker (‘SW1’ in the report) made two initial visits, on one of which a man, assumed to be Hunjan, was seen at the flat. While SW1 “addressed the most immediate issues of concern during these two visits… she gained very limited information about [Hunjan],” the case review said. On 30 July SW1 received information that Hunjan was in custody following a “life-changing” assault on a neighbour of Tayler-Morrison.
‘Over-optimistic decision’
Having completed her assessment in August 2015, SW1 recommended the family’s case proceed to an initial child protection conference because of Tayler-Morrison’s reticence and a lack of knowledge about Hunjan and Noah’s father. But this decision was overruled by her team manager, in favour of a child in need plan under which more information would be gathered.
The review found this an “over-optimistic” decision, but a legitimate one “given the expectation inherent within the Children Act 1989 that, where possible, social workers should work in partnership with families at the lowest level of intervention”.. The case was reallocated to SW2, a newly qualified social worker, in September.
Shortly afterwards, police reported to SW2 that a “loud argument” had occurred at Tayler-Morrison’s address. Due to concerns that Hunjan may have come within the M25, social workers requested a welfare check on Noah, who was found at Hunjan’s bail address in Hull.
Over the next few weeks SW2 interviewed all the adults involved with Noah and, the review noted, “was concerned about the violence that Child J had been exposed to and discussed with Mother the risks that Z could pose”. But no multi-agency meeting to discuss the risks further was held, prior to Tayler-Morrison and Noah’s sudden move to Luton on 12 October 2015, where “unbeknown to Ealing staff” they were joined by Hunjan.
‘Risks not obvious’
In the wake of Tayler-Morrison’s move, SW2 sent detailed case documents to the RIAT at Luton. “All the information about past and current risks were included in the information and at the time the staff in Luton thought that it was a full referral; however with hindsight it is apparent that the risks posed by Z were not immediately obvious,” the review found. “The information provided was misunderstood and Luton practitioners considered that the immediate risks to Child J had been resolved by Mother leaving London and removing them both from the orbit of the father.”
The report also noted a “pressured” environment in the RIAT at the time, with raised caseloads, high staff turnover and senior managers concerned about the impact of London boroughs placing vulnerable families into the area because of its cheaper housing.
“Staff did not feel they had sufficient time to read and understand all the information provided by the Ealing social worker,” the review said. “Without effective management of resources at the ‘front door’ any structure will be unreliable and will undermine the wider safeguarding processes.”
A decision was taken to provide support via Luton’s early help service without any contact with Tayler-Morrison. Nor were the documents from Ealing passed on to the health visiting service who made an initial visit to the family on 18 November 2015. Noah died the following day.
Responding to the SCR findings, Mahmood Hussain, Luton’s elected member for children and young people said that the borough had reviewed its practices in the wake of Noah’s death, and had now installed its own multi-agency safeguarding hub in place of the RIAT.
“We changed our procedures so that when we are informed by another local authority that they are transferring a child in need case to our area we, automatically carry out an independent assessment of the child’s needs,” Hussain said.
Hussain added: “With increasing numbers of children moving across more than one local authority area and involving a number of agencies, there is a growing pressure for a national format for the transfer of CIN cases [which] should take a similar approach as exists in relation to children subject to a child protection plan.”
Sheila Lock, independent chair of the Ealing Safeguarding Board, said: “The review highlighted the inconsistency experienced by all local authorities when child in need cases are transferred. National guidance would bring consistency for all agencies and immediate benefits in safeguarding children, especially for those families who move around the system.”
Lock added that Ealing now follows the same procedures for families transferred into the borough under child in need arrangements as it does for those with child protection plans. “For cases transferring out of Ealing, the process includes a review of case records by a child protection advisor,” she said.
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Actually not only is it a failure of sharing information could this issue be resolved if the UK had a national data base for recording such information that was assessable by other professionals and transferable to other local authority areas. Ah hold on wasn’t that an idea after Victoria climbie in 2001! which then fell flat??
This is not violence ‘between adults’ – name it for what it is i.e. MALE violence
I am a fossil but we have had these problems with families moving between LAs time and time again for years and years and years – what will it take for the people are paid very high salaries to sort this out – how much longer will it continue!
Not convinced about the need for new procedures and new national guidance…
This is not rocket science surely?
– share information within and between local authorities.
– assess and update previous assessments. assess males /fathers as well as fenales/mothers
– know the difference between child in need work and child protection work.
– understand the dynamics of resistance and denial in families, especially in the context of interpersonal violence.
if there should be any national guidance or questioning, it should be about the practice of London local authorities transferring families to other areas to ease their housing crisis.
The problems in this case were not caused by a lack of information but by an inability to understand the information and to recognise the dangers to an infant.
In both authorities decisions were made to work with the family at the lowest level of intervention but this did not mean that they could ignore their duty under s47. The case was repeatedly regarded as a ‘child in need’ case when in fact there had been a series of incidents which, if properly understood, would have indicated that the case had reached the threshold of ‘child protection’ and protective measures should have been put in place. In fact, the Ealing social worker had recommended that the case should proceed to an initial child protection conference but this was over-ruled by her team manager.
Time is a crucial element in work with children who need protection from significant harm but the urgency of the situation when it was transferred to Luton was apparently not made clear. It is easy to understand why a case referred from another authority may be dealt with in a superficial way if it is a ‘child in need’ case but possibly the new authority should have made a fresh assessment – and not relied on the previous one.
What I don’t get… is that you say there was an inability to UNDERSTAND the information. I beg to question why people are lets say “trained” in certain fields to their job role etc. I myself & many more people I guess have worked overtime. .let’s say to get a job done correctly or to desired effect for any reason… safeguarding.. if I were to put extra hours in any paid job that would benefit a child/vulnerable person – then I would do my upmost to see that all areas of expert care is sought, planned, written up, documented, referred etc etc etc…. nothing can bring back an innocent child ..victim of abuse & i think sometimes that even trained staff can suffer stress related work issues but we need a better updated service that can recognise & use information in the correct way.. also if you feel that the problem was from not understanding – where is the learning & to what extent do we need to help further similar situations ?
The SCR does not make clear that Children’s Services has a statutory duty under s.47 to assess risk. It was not good practice to continue working under a CIN plan because managers should have been alert to the risks of physical harm to a very young child, particularly as there were escalating child protection concerns. Social work intervention did not focus on this risk clearly enough, nor did it highlight the dangers from mother’s partner who was bailed following a violent incident.
I am surprised that the profession does not seem to realise that children under one are at the highest risk of homicide of all age groups and have a sound grasp of what this means in practice. After a 3 year degree I would expect all social workers to be able to think clearly about risks to infants and to write coherently about the precise nature of any dangers to an infant when transferring a case.