Serious case reviews into toddler murders highlight social work staffing and oversight failures

Northamptonshire investigations find practitioner turnover, ineffective management and unreliable IT fuelled drift and delay in children's services


Social worker shortages and system failures left a children’s services department “ineffective” in the cases of two toddlers who were murdered, serious case reviews have found.

Investigations into the killings of Dylan Tiffin-Brown and Evelyn-Rose Muggleton, both by men with histories of violence, highlighted drift and delay fuelled by staff turnover and poor oversight at Northamptonshire council.

No social worker saw Dylan, who was two, in the two months between him being discovered at his father Raphael Kennedy’s home during a police drugs raid and his death at Kennedy’s hands – with several substances in his body – in December 2017.

Evelyn-Rose, who was one, was killed four months later by her mother’s new partner, Ryan Coleman. Investigators found social workers, who changed regularly, were over-optimistic in their dealings with Evelyn-Rose’s mother, failing to assess risk and paying “little if any attention to the wellbeing and needs” of her children.

Earlier this month the government announced that children’s services in Northamptonshire would be turned over to an independent trust ahead of the county being split into two new unitary authorities.

The move followed a scathing review by commissioner Malcolm Newsam, which found child protection services in chaos and a breakdown in trust between staff and senior managers. An Ofsted visit in autumn 2018 described the county’s social workers as “overwhelmed and drowning”.

Northamptonshire’s director of children’s services (DCS), Sally Hodges, said the cases were “a matter of considerable shame” for the council and that there were “no excuses”, but that the new trust offered an opportunity to turn things around.

Matt Golby, the leader of the troubled Conservative council, which has twice declared de facto bankruptcy, yesterday resisted calls by Andrew Gwynne, the shadow communities secretary, that he step down in the wake of the reviews.

‘History of domestic incidents’

The investigation into Dylan Tiffin-Brown’s death found that many agencies had been involved with his mother and with Kennedy and his family over a period of years.

“[Police reports] note a history of domestic incidents (from verbal arguments to serious assaults) involving Father, his partners and with his brother,” the review said. “Children’s services were involved separately, respectively, and to differing degrees of formal involvement, with [Dylan’s] paternal siblings and families.”

Dylan was subject from birth to a child protection plan, though this had been stepped down by the time he was found in Kennedy’s flat with “apparent access” to drugs and signs he had been left alone for long periods. Kennedy had discovered he was the boy’s father just weeks earlier, in September 2017, meaning professionals had only recently become aware of informal shared care arrangements he had regarding Dylan.

A strategy meeting held soon after the search of Kennedy’s flat decided that the section 47 threshold was not met, because of Dylan’s involvement with universal services and the fact he had suffered no harm. A follow-up referral to children’s services’ first response team included stipulations that social workers interview both parents, Dylan be seen at home and a range of agencies feed into an assessment.

Over the following weeks reports continued to made, both by family members and professionals, regarding Dylan’s unsupervised contact with Kennedy.

Two days before his death an independent reviewing officer (IRO) warned Dylan’s allocated social worker and their manager that a parenting assessment was being carried out, as part of separate proceedings, due to concerns around Kennedy.

The IRO observed that nothing had been recorded on Dylan’s file since October.

‘Ineffective’ case management

A report submitted by Northamptonshire council to the serious case review admitted that the failure to see Dylan in the weeks after the drug warrant was a significant missed opportunity and meant “his voice was not heard”.

It also acknowledged that the strategy meeting around Dylan “failed to fully appreciate the significance of [Father’s] chronic history of domestic abuse and extensive history with the police for drug-related offences”.

The serious case review said professionals at the strategy meeting may also have been over-optimistic about the capacity of Dylan’s mother to manage risk.

It further quoted Northamptonshire council as saying that thresholds were being inconsistently applied, with too much focus on imminent danger, and that a section 47 inquiry should have been commenced in October 2017.

The review listed a string of factors contributing to how Dylan’s case was handled, describing case management and communication within children’s services as “ineffective”. It said high staff turnover, management sick leave, inadequate monitoring and unreliable IT systems were all hampering the effectiveness of child protection teams at the time.

‘Positive engagement’

The investigation into the death of Evelyn-Rose Muggleton, whose father also had a long history of domestic abuse and was in prison when she was born, similarly identified problems around staff churn.

A social worker who helped instigate child protection plans for Evelyn-Rose’s siblings shortly before her birth then went on sick leave, to be replaced by another practitioner who focused too little on the children’s lives.

This social worker did not explore whether the children’s mother had completed the Freedom Programme, which helps domestic violence survivors make sense of their situations, or challenge her poor engagement.

“Social Worker 2 recorded positive engagement on the part of Mother, despite a lack of visits to the home and the children not being seen,” the review said.

“It is of further concern that when Social Worker 2 did visit Mother at home, knowing she was pregnant, he did not discuss this with her,” it added.

Cases ‘quickly closed’

As a result, the child protection plans were stepped down to child in need, after which point the review said they began to drift. When a new practitioner took them over following Social Worker 2’s sudden departure they were “quickly closed” despite a community midwife’s objections.

After Ryan Coleman, a prolific offender who refused to work with professionals during time in care as a young person, moved into the family’s house during 2017, both police and the school attended by Evelyn-Rose’s siblings missed opportunities to share concerns with social workers, the review found.

The police subsequently passed intelligence to children’s services on several occasions. But the information, relating to drug dealing at the address, was never followed up in Northamptonshire’s MASH due to it being unverified.

Children’s services also failed to consider Evelyn-Rose’s siblings’ needs after she suffered the brain injury that killed her in April 2018, the review found.

“There was no consideration at [strategy meetings] of potential wider concerns for the children and what they may have witnessed in the household prior to [Evelyn-Rose] being fatally injured,” it said. “Additionally, there was no legal advice sought or discussion about where it might be safe for the children to live or how these decisions had been reached.”

‘Systemic faults in our systems and management’

Responding to the reviews, Northamptonshire’s director of children’s services, Hodges, who started in her post in February, issued an “unreserved apology” to the family of Dylan Tiffin-Brown, who she said the council had let down and failed to protect.

“The systemic faults in our systems and management practice at that time were simply not acceptable and contributed to this child being left in the care of his father who ultimately murdered him,” she said.

Hodges added that many services had missed chances to raise the alarm in Evelyn-Rose Muggleton’s case.

“There is simply no excuse that agencies failed to share information amongst each other which if put together earlier would have led to a far more realistic picture of the risks this child was facing,” she said. “For our part in this failure and for the poor decisions made within social care we are truly sorry. We let this child down.”

Hodges said that weaknesses, including around delays to cases being allocated and actioned, and relating to management oversight, were being addressed.

She also told local reporters that some social workers had been disciplined or had left the council in relation to the two serious case reviews.

Keith Makin, chairman of the NSCB, said: “There is no doubt that these two high profile cases will raise genuine concerns about some elements of the child safeguarding sector in Northamptonshire at this time.

“I have to acknowledge that, but I am confident too that significant progress has already been made and continues to be in terms of the learning and process improvements which have taken place since,” Makin added.

“Ultimately, it seems unlikely that anything could have been done to prevent the single, catastrophic incidents which led to these, but every effort is now going in to preventing a repeat of these tragic cases.”

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5 Responses to Serious case reviews into toddler murders highlight social work staffing and oversight failures

  1. Ray Jones June 6, 2019 at 5:14 pm #

    Terrible killings by violent men of two little children in Northamptonshire in the midst of a county council which had created uncertainty and instability in its children’s social services by its ideological commitment to out-source the service. And this is now to be compounded by the government ordering that the service be outsourced anyway. Crazy. Instead of the focus being on building a stable secure workforce and management focused on children and families in their communities there is to be the distraction of creating a new trust. This introduces more costs and is likely to take a year plus to create and then another year plus to embed. There will then be the continuing additional cost and complexity of the two new Northamptonshire councils being accountable for a service where their only influence is through contract management to an independent company outside the transparency of the public sector.

  2. john stephenson June 7, 2019 at 5:35 pm #

    In 2013 N.C.C. drafted in a body of Complaints Investigators to deal with a backlog of Complaints(of which I was one) .Several issues were identified (one social worker I interviewed had a Child Protection Caseload of 66) .However there was no political will within N.C.C. to implement reflective open practice,and as a result critical reports of the Authority were not welcome .
    I am afraid N.C.C. are authors of their own downfall.

  3. Opallady June 12, 2019 at 3:39 am #

    I have worked at NCC on two occasions as an agency Social Worker. I met committed hard working people who were doing their best. .A lot of workers had left their homes around the UK (and beyond), to work there.

    My experience was very ‘mixed’ indeed..

    Although mention of ineffective management on several levels. What’s not been mentioned is how some of us agency workers were treated…usually with contempt and disrespect! Examples of this are senior managers who acted as if some of us were invisible.. Not even a good morning..also ignored if we didn’t manage to ‘hit the targets’ she required.

    Some workers worked at NCC for long periods of time without a problem. When it came to leaving, that was something else..

    I, and many other workers (mainly black) received unfair, unbalanced and poor references, which were challenged, in some cases by legal avenues.

    Some local workers chose to work outside NCC, travelling long distances. That says a lot.

    Blame culture was a regular feature, some managers were of the opinion as ‘agency workers are being paid more’…They expected us to have extra arms, legs and powers to churn out more work. No mention of the unrealistic case loads or some aspects of their inadequate IT system.. The list is endless!

    I for one am glad to hear NCC is being managed by a trust. I just hope that mangers at all levels treat Social Workers how they wish to be treated, with RESPECT!

    This ‘news’ has come as no surprise.. In life we reap what we sow! Little wonder that Social Workers have been avoiding NCC like the plague for a long period of time.

    My only concern is the impact on children and families.

    On a positive note, Northampton is a beautiful area. I met some kind and decent people both families, people I stayed with and colleagues who remain friends:-)

  4. Anon June 14, 2019 at 6:49 pm #

    Unfortunately NCC is going through a tough time and clearly there have been failings.

    I have never worked there but there are other local authorities where the workers are treated with such contempt and cases against them are made up; workers are considered guilty unless proven otherwise.

  5. Gayle June 19, 2019 at 5:09 pm #

    You’re right Opallady about how Agency workers are often treated with disrespect and contempt. My question is, if permanent social workers and their management think we have it so good, why are they not all jumping on our bandwagon??