Serious case review questions ‘value’ of supervision orders

Review says murder of Ayeeshia-Jayne Smith by her mother could not have been predicted, but criticises ‘lack of professional curiosity’

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The management of the case of a girl who was murdered by her mother while under a supervision order has been criticised by a serious case review.

Professionals working with Ayeeshia-Jayne Smith, who died, aged 21 months, in May 2014, lacked understanding about the supervision order the child was subject to and felt it was “somehow a lesser process” than a child protection plan, the review said.

The supervision order “may have deflected professionals’ focus away from the original safeguarding concerns” present before the birth of Ayeeshia-Jayne, and there was a “lack of an outcome-focused” child in need plan.

Review author Jenny Myers said the issues she identified with the supervision order had “wider significance for the child protection system”, and that she “questions the value of supervision orders in current practice”.

Ayeeshia-Jayne was killed by her mother, Kathryn Smith, at her home in Burton-on-Trent, Staffordshire. They had previously lived in Derbyshire, and had been in contact with Derbyshire council’s children’s services.

Kathryn Smith was found guilty of murder and child cruelty, while her boyfriend Matthew Rigby – who was not Ayeeshia-Jayne’s father – was found guilty of causing or allowing her death.

Jane Parfrement, Derbyshire’s strategic director of children’s services, said the council accepted the findings and recommendations in full “and takes full responsibility for its actions in this case”.

“We have already taken action to improve the safeguarding of children in Derbyshire and will continue to do so,” she added.

‘Lack of professional curiosity’

The serious case review, published this week by Derbyshire Safeguarding Children Board, said professionals “should have been more inquisitive” about the impact of the mother’s boyfriend and her other relationships on the child’s safety and health and welfare.

It said: “Professionals made much of the positive relationship observed between [the mother] and her child and this appeared to lead, at times, to a prevailing sense of optimism and a lack of professional curiosity about the current partner, violent incidents, drug use and his care history and background.”

However, the review said the mother’s actions could not have been predicted.

Key professional interventions

May 2012: Referral made to Derbyshire children’s services after information received around Kathryn Smith’s mental health and history and possible risk for her unborn baby.

July 2012: Birth of Ayeeshia-Jayne Smith, child protection plan in place.

May 2013: Care proceedings initiated and Ayeeshia-Jayne made subject to an interim supervision order.

June 2013: Ayeeshia-Jayne made subject to interim care order and placed with foster carers. Mother to start a support group in regard to domestic abuse.

October 2013: Care proceedings concluded. A 12-month supervision order made to the local authority. Parental responsibility given to birth father and Ayeeshia-Jayne returned to live with mother.

January 2014: Child protection medical undertaken on Ayeeshia-Jayne due to hair loss (bald patch on head which was confirmed as alopecia)

February 2014: Ayeeshia-Jayne taken to Queen’s Hospital Burton by ambulance following sudden collapse at home and supposedly witnessed fit. She was admitted to the paediatric ward for observation and urine sample, but discharged in the early hours of the following morning. At the end of the month, Staffordshire children’s social care was informed that the family was moving to private rented accommodation in their area, and that Ayeeshia-Jayne was subject to a supervision order.

May 2014: Ayeeshia-Jayne died after being taken to Queen’s Hospital Burton by ambulance as she was in cardiac arrest.

Of supervision orders, the review said that, if there was ongoing risk, “it might be more appropriate for children’s services to consider if a care order with placement to parent/s would be a more suitable option. Alternatively supervision orders should as a minimum have a CPP [child protection plan], rather than a CIN [child in need] plan alongside it.”

It also said professionals should be clear that if concerns about the safety or potential harm to the child begin to escalate, a supervision order “does not prevent a parallel process of child protection taking place”. In this case, “there seemed to be an assumption made by professionals that the main option open to them in light of their increasing concerns was to go back to court.”

‘Authoritative practice’

The review said there “was evidence of initial appropriate multi-agency practice by a group of committed workers who mostly communicated and worked well together”.

It added: “This is not a case characterised by a repeated lack of adherence to procedures. However, the multiagency practice became less organised once the supervision order was made and this is significant.”

It also found that there was “not enough evidence of authoritative professional practice” that saw Ayeeshia-Jayne as the “primary client”, and this resulted in “a fixed view that attachment and parenting continued to be good enough as risks increased”.

The review said: “Some of this was caused by the professional view that [the mother] was difficult to engage with. In exploring in more depth with the practitioners as to why this was, and what strategies were used to address it with her, it became clear that it is a feature for professionals working with not just this case, but others, and that this leaves some of them feeling immense frustration.

“Authoritative practice is also about being clear about what a home visit entails, the complexity of managing the often unpredictable environment and how to make it meaningful in carrying out assessment tasks.”

 ‘Hidden men’

Other issues identified in the review included:

  • there was little recognition of the role the mother’s boyfriend and child’s father were playing in the girl’s life. This resulted in a lack of professional assessment of both the benefits and risks they posed both to the mother and child.
  • hospital emergency and paediatric staff “did not sufficiently consider whether child abuse or neglect was a possibility” when Ayeeshia-Jayne presented with medical issues during the last few months of her life.
  • it was appropriate that Ayeeshia-Jayne was made the subject of a child protection plan at the time of her birth, but 10 months later professionals were too focused on the needs of her mother, and the risk she was deemed to be at as a victim of domestic abuse. An “unduly positive picture” of the mother’s capacity to parent safely went unchallenged and the daily lived experience of life for Ayeeshia-Jayne was “somewhat lost”.

Problems with written agreements

The review also highlighted concerns over written agreements, saying their use and requiring individuals to sign them needed “caution”.

“They may be effective if the adult/s are central to their development, feel able to comply with realistic expectations, and are clear what the consequences are if they are not adhered to,” it said.

The review added: “Good practice would suggest that written agreements are a statement of the local authority’s concerns and advice to a parent, that they are not a contract and therefore there is no requirement for parents to sign their agreement.”

Asking the mother to sign a written agreement to cease contact with another boyfriend “was not helpful and placed an unrealistic expectation on her”, it said.

This was “later validated” when the mother, in talking to the lead reviewers, acknowledged that when asked to sign a written agreement not to see Rigby, “she would not sign it as she had no way of enabling it to be adhered to based on her past experience”.

The review added: “The role of written agreements… appears to be common and, yet, it is known that women who are in situations where domestic abuse is a risk will find it very hard to comply with such an agreement. If they are used, social workers need to be clear with families as to their purpose, and consequences of non-compliance.”

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14 Responses to Serious case review questions ‘value’ of supervision orders

  1. ann September 6, 2017 at 3:13 pm #

    Tragic story awful but of course the murder cold not be predicted, but surely it was identified that the child was at risk of significant harm and safeguarding steep should have been taken. Stating that it could not be predicted is almost a way of letting agencies off the hook. I read that statement all the time in all SCRs and it has to stop as it is meaningless.

  2. Ruth Cartwright September 6, 2017 at 5:46 pm #

    Interesting how health professionals as well as Social Workers are called to task and have lessons to learn, yet the media coverage only mentions Social Workers.

  3. frustrated September 6, 2017 at 8:42 pm #

    I wanted to have the children on my case load that were on Supervision Orders taken to an ICPC but management were insistent this was not possible. Whilst the police were advising me they could not work on the case unless it was CP.
    I have not practised SW for a year because my manager wanted to minimise and simplify the complexity of the case so it fitted within her lifestyle.
    The lawyer wanted photographic evidence from a mother who shouted and screamed what ever, just image the extra distress if I requested permission to take photos for court!
    Having been through the court process, she dehumanised me as a social worker. The judge made decisions without any direct communication with the parents.
    The family were skilled manipulators and had learnt they could evade all concerns. I tried to remain focused on the children as did other professionals, it was the courts, managers that let these children down . Supervision Orders are worthless.
    The individual SW can remain focused on the child, be inquisitive but they will suffer for it as no-one wants to listen.
    I was told by a senior manager that Supervision Orders were for showing that the parents could cope on their own!!!

    • Kent social worker September 9, 2017 at 11:10 am #

      I do understand your frustrations, and I do not intend any criticism. However we should remember that as case managers who know the children and families best, we have to be able to challenge our managers in respect of decisions they wish to make on our behalf, and importantly ensure that these are recorded as a management discussion on your electronic case file. As social workers we must try to develop this confidence of professional challenge, as we are accountable.

      In the case of a supervision order, I wholly concur that CP plan should be alongside particularly during care proceedings. Supervision plans are NOT worthless however, and are an indication that the Local Authority, Court and Guardian all have concerns and the onus is on the parents to abide by the supervision plan i.e. comply with Parenting assessments etc, and the CP plan which will include regular core group meetings, which discusses and monitors the overall plans, and CP visits, alongside the oversight of the court and the guardian.

      On this point, there is the duty of the children’s guardian to work alongside the Local Authority and best practice lends itself to a positive and communicative relationship between the social worker and guardian. Yes, the guardian has influence in court, but DOES NOT know the child better than the social worker. More guardians should attend interim meetings like core groups and CP reviews, but very few do, which is not helpful.

      We must remind ourselves as social workers that during proceedings, we are under tremendous scrutiny as we have lodged the court application, and so we have to be accountable for best practice. However, this is why presenting best evidence and challenge where necessary in the best interests of the CHILD is paramount. Because if things go wrong it will be the social worker that cops it – the other parties including the Guardian will pale into insignificance and not take any responsibility for their part in the decision making put to the court.

      The public do not know the efforts, time and dedication that social workers invest in every case, and the constant criticisms made by parties when something hasn’t or even HAS been done. So rather than be defeated, we should rise up and defend our knowledge, skills and values, and defend our professionalism as defenders of child protection. The other parties all have their own agenda, it is for us as social workers to provide a strong argument to the court that we know what we are doing, and not get downhearted that unfortunately whatever we do others will want to dim our light. Remember we are doing a brilliant job that most people who criticise would not want to do, and that includes Guardians who are qualified social workers, but no longer sadly in front line practice, and sometimes forget the constant pressures and the management hurdles that social workers have to contend with to protect children.

  4. Anita Singh September 7, 2017 at 3:43 pm #

    Dear Frustrated, I could not agree with you more. I had a case where the LA allocated it to me in the middle of proceedings, which ended with another SO, when one had already been very poorly adhered to. The parents’ legal counsels argued there was insufficient evidence to prove mother’s active collusion and covering up that her partner was still living with her and gaining access to their son, when the previous SO had clearly stipulated absolutely no contact. Despite the evidence, which the Judge refused to hear, the Judge then asserted that the LA had not provided enough evidence!

    The child had already experienced a fractured skull, ribs, wrist, a bleed to the brain and punctured lung when he was just a one week old premature baby, which was concluded with the first SO. Yet despite clear historical evidence that the injuries were inflicted by the father, it was decided that the injuries were due to ‘accidents’, so the baby was made subject to an SO which was poorly complied with. The Judge still decided to believe the mother’s assertion that the father was not having contact. What did the LA get in Court – oh yes – another useless SO.

    It is hardly surprising when you get such cases being subject to the limp decisions in Court where the Judge wants to invariably play hard ball with the LA and perceives some injustice to the family when one does not exist and another SO, not worth the paper, was issued. If something goes wrong guess who is going to be blamed….

    The latest buzz word is the “Risk Averse” social worker. Well the Courts are certainly playing Russian Roulette with children’s lives, as Judges can comfortably sit in their ivory towers, happy to blame the SW when it goes wrong, with yet another Serious Case Review of Enquiry funded by the tax payer to achieve more conclusions that we already know.

    I made it clear that I was not prepared to even try to manage such risk with such an inadequate order. On that occasion, another overloaded but possibly less ‘Risk Averse’ social worker got the case who is no doubt relieved that the child has not died on her watch……

  5. Chris September 7, 2017 at 4:18 pm #

    There’s a huge lack of understanding about SOs – in LAs I’ve worked in, the SO cases get treated as though they have minimal concerns, even though (by definition) they meet the threshold for care proceedings!
    While every case is different and I’m wary of putting cases ‘in a box’, by default I’d see an SO as a situation more dire than a CP case but not quite serious enough for a child to be removed. This isn’t reflected in the case management.

  6. frustrated September 7, 2017 at 5:45 pm #

    Yes Chris, I agree about the seriousness of Supervision Orders yet they are still managed as CIN if they hadn’t already been through courts they would be CP. There may be some case(s where Supervision Orders work but in my experience they make social workers ill another whammy as mangers want to hide fact case was not worked for a length of time). (because they have been given an impossible task.
    Managers did not like my assessment because it did not say what they wanted to hear and maybe because I analysed the psychologist’s assessment probably which should have been done by the practitioners at the time. I challenged the health professionals who provided very different accounts verbally and in writing which may explain why certain evidence was not found during court process.
    In another Supervision Order I inherited the expectations on the mother to unpick her situation were unrealistic and set her up for failure which anyone with any ounce of common sense could see that.
    Yes social workers get blamed but we should we be standing up collectively and saying what is really happening and that in reality the system uses tax payers monitor to monitor and review but in this economic and social climate make no difference because the law is outdated.

  7. Ann Edwards September 7, 2017 at 9:28 pm #

    I agree with earlier comments. I have always thought that there needed to be a CP plan if children were made subject of a supervision order.
    I would like to comment on several aspects of the case which are recurring features in cases of neglect.
    Firstly, professionals are often casual about children not being taken to follow up health appointments or who are prematurely removed from inpatient care, both of which happened in this case. When I looked in detail at a number of CP cases in my own l.a., this was a factor in all cases and resulted in very serious and lifelong health problems for some children. Either it was unreported to the social worker at the time or the social worker didn’t regard it as significant especially where the child was one of a large family, the view often being it was only to be expected due to the burden of parenting a large family.
    Secondly, one of the unrecorded and therefore uninvestigated concerns before the death of this little girl was the pattern of her progress as measured by weight gain. What was later discovered was a drop down the centile chart when in the care of mother compared with good weight gain and progress in foster care. Also the independent investigator noted that she settled down and progressed well in foster care, in fact unusually well for a child who was supposed to have a good and secure attachment to mother.
    It was also noted in the SCR that the views of the foster carer and her concerns ( including concerns about the mother and feeding of the child) were not heard and did not therefore have an impact. It was suggested that the availability of a foster carer’s log would have helped to inform the child care plan when the child was discharged from care. In the local authority where I previously worked, it was routine to obtain a statement from the foster carer which was filed in the proceedings. Occasionally the foster carer would be asked to give evidence and this was always much appreciated by the Judge in assisting decision making. Further, our foster carers were required to keep diary records which were regularly shared with the child’s social worker and which could also be seen by the Guardian. I find it worrying that these practices are not more widespread.
    Lastly, was a chronology kept by the social worker after the end of the proceedings? This is such a helpful – and powerful – document if it contains all relevant facts
    Child care social work with neglectful and devious parents is hard enough. It is troubling that basic steps which would clarify what is known about the child (and is not dependent on what the parent tells us) and which would assist in safeguarding children, still aren’t routine.

  8. Elizabeth September 10, 2017 at 9:02 pm #

    The threshold for SO is the same as a Care Order….but LA’s don’t like to have a Care Order at home…..Just mindful people need to be careful about their posts as they may inadvertently be identify families they have worked with. Terribly sad case; again.

  9. Tom J September 11, 2017 at 2:02 pm #

    I’ve always found it odd that you have huge worries about a child and decide that the child protection plan is not sufficient so you go to court. However, should you come away from court with a supervision order you end up with less than what you started with i.e. it drops from fortnightly to monthly visits, and multi agency meetings drop from monthly to tri monthly.

    Its worth noting that its rare in my experience that a social worker goes to court with the aim of getting a supervision order as these are well known to be watered down child protection plans. More likely is that a care order is sought which is dropped down to a supervision order through the court process.

    • Kent social worker September 13, 2017 at 11:11 pm #

      I’m afraid I do not agree that social workers don’t go to court with the aim of getting a Supervision Order, particularly on an interim basis. Of course we do!! However there needs to be clear evidence that although there are concerns, it is not always appropriate to adopt the draconian method of removal by care order. You have to have a sound argument that the child is at risk of significant harm, failing to thrive etc.

      Supervision Orders meets threshold for significant harm but then assessments are usually carried out in accordance with the relevant care plan, and usually the child or children are at home so of course it would be best practice to ensure that a CP plan runs alongside! How else will the LA monitor welfare concerns that meets threshold?

      The courts may have oversight but it’s still the responsibility of the LA to ensure the child’s safeguarding with CP visits and regular core groups, which will update professionals as to the progress of the plan within care proceedings.

      If you have concerns for a child on a CP plan, you do not as a matter of course go straight to court unless the child is at risk of immediate harm. Pre-proceedings, should come into play which is preceded by legal planning meeting, to ensure threshold is met. Surely other LAs carry out this standard practice, and which is prevalent in my area, particularly with neglect cases? Evidence has to be gathered to let the parents know the extent of the LA concerns, what the LA has done to support, and what will happen if the plan within pre-proceedings does not make progress.

      It’s quite usual that the case will already be at the CP stage, but if it isn’t, best practice would suggest that a Strategy meeting is convened to discuss with professionals whether it should be.

      So Andy and Tom, please consider that whilst the court, guardian and whoever else may have oversight, it is the social worker who is responsible for the child’s safeguarding and welfare on a Supervision Order, within care proceedings, and the onus is upon the parents to demonstrate parenting capacity to ensure the child will be safe throughout its minority years, and if not you have your evidence to put before the court that either a suitable family member can care for the child, or other placement options In line with Re BS, which may or may not require a care order/ placement order/adoption order for the child going forward.

      Supervision Orders should be used appropriately and supported by CP plan in my view which should enable the social worker to assess what is right for the child in the longer term.

  10. Andy September 12, 2017 at 11:51 am #

    Hmmmm….. playing devil’s advocate here, but if an LA goes to court and the court makes a Supervison Order, why would a CP plan be required? The Courts have had oversight of the case and concluded that while the threshold for significant harm is reached, the Court has deemed the parenting to be good enough for the child to remain at home. What IS needed is a robust plan, which if not followed by parents or if risk increases needs to be returned to Court, surely?

    Lots of LA’s in Greater Manchester are being given Care Orders at home at the conclusion of proceedings when seeking removal on the grounds that while the threshold for significant harm is met, that harm is deemed not to be serious enough for the children to be removed. This, in my view leaves children even more vulnerable as the Local Authority SW’s and IRO’s have to manage these cases because Courts will not sanction a removal from parental care. And of course, should anything go wrong in these cases eg Ellie Butler, where is the judicial accountability?

  11. Planet Autism September 13, 2017 at 3:20 pm #

    And yet children are put on CP and removed all the time for alleged emotional harm, quite often where none exists. So why do cases of children being physically abused keep ending in murder and serious case reviews? The system is all wrong. Having just read the case of Medway removing children for alleged emotional harm purely because the mother home-educated, it’s quite clear that the over-zealous misuse of emotional harm law is at great detriment to genuine abuse cases.

  12. Rosaline September 16, 2017 at 11:37 pm #

    Supervision order, child protection plan, child in need plan, irrelevant of status, the status would not have safeguarded the child. Basic social work practice and basic management oversight, would have enabled through supervision slow thinking, curiosity, exploration of information, hypothesising, analysis and decision making.

    I have worked with many cases with a supervision order, the status of a court order supersedes a child protection or child in need plan. Whilst the order is in place the matter can be restored to court within timescales pursuant to an emergency protection order. This is not about case status but practice.