Inconsistent multi-agency working, “reactive” practice and over-optimism meant social workers and other professionals missed opportunities to intervene in a family where a toddler overdosed on methadone, a serious case review has found.
Two-year-old Frankie Hedgecock died in June 2015 after drinking a cup of methadone left on the floor by her mother Lucy King, who had fallen asleep. King was convicted of manslaughter through gross negligence in April 2017.
The serious case review, published by Kent Safeguarding Children Board, said no single agency or professional – all of whom “wanted the best” for the family – could have predicted Frankie’s death.
But it found there was a collective lack of insight into the lives of Frankie and her four siblings. This was exacerbated by an excessive focus on King and her partner, both drug users, and the absence of a chronology of events that might have enabled better analysis of their situation.
The review recommended all agencies use chronologies and called on Kent children’s services to provide the safeguarding board with reports on multi-agency participation in child protection conferences twice a year.
Kent County Council children’s services had been sporadically involved with King since the late 1990s. Some referrals related to health professionals’ concern that her methadone use while pregnant could affect the welfare of her unborn children. Other referrals followed King’s failure to bring her children to check-ups and other medical appointments.
Members of the public also contacted children’s services on a number of occasions concerned for the wellbeing of King’s children. In 2010, one caller stated that the children “do not see the light of day”. Ambulance staff who attended the family’s home a few months later described it as run-down and cold, with no furniture, carpets or wallpaper.
However, social workers visiting the family home generally found that King and her partner were doing their best and that the children were happy and loved.
“Mother and father are conscientious parents and they are moving forward in providing a better home environment for their children,” said a January 2011 initial assessment completed in response to the ambulance staff’s concerns. “The walls had been painted, new furniture had been bought and much of the groundwork had been prepared for laying of new carpets, for wallpaper to be bought and new bedding.”
A number of incidents were reported during 2012. In March, police were called after being told three of King’s children had been left in a car crying and screaming, while in August they were told that a child had been screaming “in distress” from the house.
That same month police were called to a domestic abuse incident between King and her partner in a supermarket car park and a neighbour told officers that the children were often left on their own.
Referrals were made to children’s services but the case was closed in late August, after consultation with health visitors and a drug support agency, because a ‘Team Around the Family’ was already in place.
In late 2012, King’s partner was arrested for a serious assault, for which he was later sentenced to nine years in prison. Shortly after this, King disclosed that she was pregnant with Frankie and a child in need referral was made.
However, no further intervention from children’s services was deemed necessary. A social worker noted that King’s children were attending school and seeing their father regularly (despite him being bailed elsewhere), that grandparents were apparently offering support and that the Team Around the Family would monitor the situation.
After being born in February 2013, Frankie spent 65 days in hospital withdrawing from methadone, but at her one-year developmental review she was seen to be doing well.
During autumn 2014, a council housing manager raised concerns about the safety of King’s young children after seeing them playing unattended. In May 2015, meanwhile, the Turning Point drug support agency noted King’s continued dependence on illicit methadone on top of her prescription and that she had missed repeated medical review. Frankie died a few weeks later.
The serious case review noted that a “high number” of professionals had been involved with the family and that there had been a number of positive observations. However, it set these in context of the series of reports made by anonymous callers and other professionals, and noted the “inconsistency” that King’s children must have experienced due to their parents’ lifestyles.
“Although the children were seen on a number of occasions and by a number of professionals, there was no documentary evidence of views from the children in seeking what their life was like,” the review said. “Apart from one assessment by a social worker, there was no other evidence that any of the children were seen alone and directly asked, ‘What was their life like?'”
The review said that professionals appeared to have focused too much on the parents’ needs rather than the needs of their children. It added that no agency had drawn together a chronology that might have enabled a “critical analysis” to be made. There were “numerous occasions” when neglect could have been considered, it concluded.
The review also found that multi-agency working had become disrupted, with agencies simply reacting to isolated incidents, in part because of the family’s “chaotic and transient” lifestyle. Opportunities for agencies to come together and agree a long-term plan were missed, the review said, and no systematic safeguarding risk assessment appeared to have been carried out.
“Overall, there was evidence within social care services and across the health services, of an absence of safeguarding supervision and case management oversight,” the review said.
In hindsight, the review said, professionals had recognised their over-optimism and over-dependence on the Team Around the Family, and that they had been blindsided by disguised compliance by the family.
Among a series of recommendations, it stipulated that all agencies make use of chronologies and ensure children’s views are sought, and that children’s services report regularly on multi-agency participation in child protection conferences.
The review noted that Kent council had introduced the Signs of Safety system, which should act to safeguard against the failings identified occurring in future.
Gill Rigg, the independent chair of Kent Safeguarding Children Board, said: “As a result of their contributions to the serious case review, the relevant partners drew up individual recommendations and action plans for improving the way they work to protect children better in the future.”
She added that the safeguarding board had accepted all the recommendations made in the report. “This is crucial as part of helping improve the safety and wellbeing of Kent children,” she said. “These have been implemented and lessons learned.”