Inexperienced social worker needed more challenge from manager, serious case review finds

The report into the death of a 14-year-old girl also found agencies felt more could have been done to support and listen to her

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An inexperienced social worker needed a “more challenging management approach” and more reflective supervision during her handling of a case where a 14-year-old girl took her own life, a serious case review has said.

The review into the death of Child L in Rochdale, published this week, said the social worker was in her first year of independent practice and needed better support to challenge a difficult family situation where a mother with problematic alcohol use refused to engage with services.

“High quality reflective supervision” in such situations could make a difference in “recognising the presence of the rule of optimism and the tendency for practitioners to give parents too many chances”, it added.

It said the support offered needed to include “reflective thinking time to take a step back and review what was known, what research in practice reminds us and how to use all of this information to reach a judgement about what Child L needed”.

The review covered a year in the girl’s life, and in particular six months of multi-agency work up until she was found dead.

A coroner ruled the death as ‘death by misdemeanour’. The girl had previously attempted to take her own life and self-harmed. She grew up in a household with domestic violence, and lived with her mother and maternal grandmother. The mother used alcohol regularly and both she and the grandmother saw the girl’s behaviour as “attention seeking”, the review said.

The review said throughout the six months of multi-agency intervention with children’s and mental health services there were many times where she made her views known, but “the extent to which her voice was heard and acted upon is questionable”.


While a coroner’s inquest concluded last month the actions of agencies did not cause or contribute to her death, both mental health and social work agencies accepted “more could and should have been done to support and listen to her”.

She was clear throughout her time working with mental health services and on a child in need plan that her mother’s drinking, and dismissive view of her mental health problems, were preventing her from having her needs met.

“Whilst this resulted in the child in need plan seeking to address [the mother’s] dependent drinking, the manner in how this occurred was naïve,” the review said.

The social worker was “somewhat out of step with the reality of this case”, the review author said. This followed the social worker saying the child’s death was a “shock” because “she believed that the multi-agency plan was making progress”.

Management support

At a child in need meeting, services made a plan for the mother to work with an alcohol practitioner “without any real reason to be confident about this”, and professionals “simply anticipated that the intervention would work without considering the consequences of it not doing so”.

It said the social worker needed “consistent management support” and more challenge to apply critical thinking to this “very complex” case.

“It is situations like this where high quality reflective supervision can make a difference in recognising the presence of the rule of optimism and the tendency for practitioners to give parents too many chances whilst paving the way to adverse outcomes for children,” the review said.

“The social work supervision was an opportunity to spot the indicators of disguised compliance and ensure a continued focus on the impact of no change on Child L.

“One can only conclude that the management oversight of this case was poor within Children’s Social Care, constancy of proposed weave between threshold applications should have been seen as a clear indicator that ML was not achieving consistent engagement.”


It found a “significant discrepancy” in recording between the girl’s CAMHS practitioner and social worker about what assurances were offered to the child and how much consideration would be given to alternative living arrangements.

It said the social worker should have made more efforts to explore alternative care arrangements for the girl.

While the CAMHS practitioner said the social worker agreed to look into moving the child out of the house, the idea of taking the child into local authority care was never fully considered. The social worker’s manager said moving the girl from the family home “had never been discussed” with him.

The CAMHS practitioner was “unable” to use organisational management processes to challenge social care about pursuing alternative care for her.

“Although an experienced practitioner, [CAMHS practitioner] had little understanding of how to challenge on behalf of a child and reported no knowledge of the LSCB procedures,” the review said.


The girl was coping with the problems at home by staying in family and friends’ houses; despite this social services told the mother to ensure the girl was sleeping in her own home.

“This approach completely misunderstood the reasons why Child L was staying away from the family home and effectively dismissed one of her coping strategies that decreased risk and increased her resilience,” the review said.

“Her attempts to find alternative living solutions were misinterpreted as her not conforming rather than her only means of achieving a degree of control over the issues she found very difficult to cope with.”

The mother had also warned the girl about bringing social services into the family’s business, with multiple references to her concern she would be “disloyal” by working with services.

The mother’s reluctance to work with services was apparent throughout the case, which made it “surprising” when a child and family assessment said she would be willing to work with them. The review author said this was a clear example of the “rule of optimism” within social work and other helping professions.

“When at play, the rule of optimism can blind practitioners to what is really going on by believing that what they are seeing is progress through the filtering or minimising areas of concern,” the review said.

Other issues raised by the review were:

  • Professionals were concerned that child in need meetings placed a greater focus on the girl’s younger sibling, who had previously been subject to intervention.
  • CAMHS and children’s social care “worked quite separately”, indicating child in need meetings needed to have a greater priority in CAMHS.
  • Children’s social care did not react to the mother bringing an unknown drinking partner into the house overnight. The girl’s social worker was on a rota to provide duty cover, so could not visit the family home, and the review could find “no understandable reason” why there was no action as a result of this.
  • The mother had, on occasion, been racist in her language and manner to the social worker. This was not recorded in any supervision discussions, and the social worker said she saw coping with racism as “part of the job”.
  • There was an “inherent weakness” in the approach to multi-agency working.
  • There was an “insufficient focus” on how the child was coping with her mother’s parenting while agencies were trying to engage the mother.
  • The child in need plan was “undeveloped” and child in need meetings were informal and lacked access to minutes and written plans.
  • Services made no attempt to contact the father due to his earlier conviction for domestically abusing the girl’s mother. This prevented practitioners from understanding her whole circumstances.

Jane Booth, independent chair of the Rochdale Borough Safeguarding Children’s Board, offered condolences to the girl’s family and friends.

“The serious case review we have published today clearly identifies the lessons that needed to be learned to improve practice when working with vulnerable teenagers and their families. The Board will continue to monitor agency action plans to ensure these improvements are made.”

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3 Responses to Inexperienced social worker needed more challenge from manager, serious case review finds

  1. Anita Singh September 15, 2017 at 6:48 pm #

    What are the reasons that CAMHS did not pick up that this young person was a serious suicide risk? This inexperienced SW is not a mental health expert and neither is her manager. Even if the SW had been able to place this YP away from her family, she may still be feeling so low that she continued to be a serious risk to herself, regardless of where she was living and alternative accommodation is not going to somehow provide a magical solution when she is that mentally distressed. CAMHS alongside an AMHP should have been considering a section assessment, if that was the level of risk and clearly they did not pick this up, despite they were providing her with a service.

    The SCR identifies that this was a very complex case, so how come the LA saw fit to allocate the case to an inexperienced worker, and to treat the girl as a CIN case rather than identifying her as a child who should be subject to a safeguarding plan with a need for expert psychiatric input?

    The SCR seems to think that it was OK for this inexperienced worker to hold the case and that her manager should have been more challenging in supervision. What appears to have been needed was for clear management direction of the case, consideration of this inexperienced worker undertaking joint work with a more experienced SW and for management decisions to be taken when the girl’s poor psychological state would have been abundantly clear to CAMHS who are supposed to have the necessary expertise to identify young people who are at this very kind of high risk and in need of far more intensive support and safeguarding.

  2. Rosaline September 16, 2017 at 11:19 pm #

    This is a rather interesting case and a reminder of the need for managers to be curious, inquisitive, attend visits/meetings with practitioners to help develop their thinking, understanding and analysis.

  3. Sarah September 18, 2017 at 9:58 am #

    ‘ The mother had, on occasion, been racist in her language and manner to the social worker. This was not recorded in any supervision discussions, and the social worker said she saw coping with racism as “part of the job”. ‘

    That’s a pretty terrible thing to not get a mention in the article at all right until the end. I think this team / manager sounds unhealthy, not supportive and keen to dodge bullets. The manager said that moving the child out of the family home ‘was never discussed with him’, as if it’s not something he should have been considering and bringing up himself? Very sad case all round.