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.”
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.”
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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