Practitioners’ efforts to protect boy before death undermined by silo working and poor record keeping

Social worker built strong relationship with looked-after teenager but serious case review criticises prioritisation of direct work over record keeping

Picture: Julien Eichinger/fotolia

Professionals’ “considerable efforts” to safeguard a boy as his needs escalated were undermined by a lack of strategic oversight of his case, a review into his death last year from drugs has found.

The serious case review for Dorset Safeguarding Children’s Board (DSCB) found that many professionals invested time and care in trying to keep ‘Child T’ safe, in the context of his multiple missing episodes and placement breakdowns, worsening mental health and drug use, and increasing criminality and gang involvement.

However, the increasing number of professionals involved with him, coupled with a lack of strategic co-ordinated oversight of his situation “considerably reduced the impact of interventions” and hampered “opportunities for the professional network to take a step back and look at what was happening” to the boy, the review found.

Prioritising case work over recording

After Child T became looked after by Dorset County Council, his social worker developed a positive relationship with him. However, the practitioner, amid significant pressures in the children’s social care service, prioritised direct work over good record keeping, which fed into the wider problem of a lack of strategic oversight.

“Whilst keeping up to date records might be viewed as a secondary task, it needs to be seen as of equal importance in terms of allowing an opportunity to account for the agency’s efforts to safeguard and promote Child T’s welfare, share this account with other interested agencies, and promote a wider assessment and engagement of the management of the situation,” the review said.

The case took place against the backdrop of wider problems in the response to high-risk adolescents in the county, with a 2018 joint targeted area inspection (JTAI) of responses to missing children, child sexual exploitation and child criminal exploitation (CCE) criticising partnership working as “ineffective” and saying Dorset County Council’s practice was “not consistently safe or effective for all children within this most vulnerable group”.

Local government within Dorset has been reorganised this year with the former county council along with four district councils being amalgamated into a new unitary authority – also called Dorset council – and Bournemouth, Christchurch and Poole (BCP) councils forming a second new authority.

Escalating needs

The serious case review spanned a five-and-a-half year period leading up to Child T’s death in July 2018, before which he had little involvement with agencies, though had witnessed domestic abuse between his parents, who separated.

Over the course of 2014 Child T was excluded from mainstream schooling due to disruptive and violent behaviour and had a referral to local child & adolescent mental health service (CAMHS) refused.

During 2016 he was reported by a key worker to be using cannabis and energy drinks, becoming sleepless and anxious and “talking about gangs, being verbally aggressive, having disturbing images on his phone, carrying a knife and threatening to stab people”.


In January 2017 he was accommodated under section 20 of the Children Act with a plan to return him to his mother within six months – though the review said this was over-optimistic because of her rejection of him.

His period in care was punctuated by instability with six placement changes including time with his mother, maternal grandmother, family friends, a foster carer via an independent fostering service, a hotel, and supported accommodation – all across three different

In March 2017, the youth offending services (YOS) also became involved after he was charged with actual bodily harm, and the following month he overdosed on medication, after which the YOS assessed him as being at high risk.

He overdosed again, on paracetamol, in November 2017, in what was considered to be a clear suicide attempt, after which the YOS assessed him as being at high risk of death by overdose or suicide in the subsequent six months.

At this point, the YOS and children’s social care considered carrying out a “critical learning review” into Child T’s case. The SCR said this decision “slipped through everyone’s hands due to human error”, a missed opportunity “which could have brought the multi-agency network together to examine Child T’s circumstances and think collectively about effective safety planning strategies”.

In May 2018 he was given a one-year sentence for robbery – following a number of other arrests relating to serious crimes – but unexpectedly released early, in June 2018, and placed in another county as a looked-after child.

Child T died weeks later due to the effects of drugs he had taken.

Missing episodes not tracked

The review found it was impossible to identify how many times and for how long he went missing, though there was an expectation that Dorset children’s services, as the lead agency for his care and planning, would have collected data on this. Data inputting issues with the council’s systems meant that a proper chronology could not be assembled, while it was suspected that some episodes were not reported by his mother and grandmother. Also, it was not possible to determine when and how rigorously return-home interviews had been carried out.

“As it has been impossible to identify the extent of the problem in this one case it would be reasonable to assume it being a widespread issue,” the review found, noting that this correlated with problems uncovered by the JTAI.

This was one of a number of record-keeping issues raised by the SCR. Both Child T’s care plan and pathway plan were started but never completed, and records of visits to Child T by his social worker were recorded significantly late.

As well as the social worker prioritising direct work over record keeping, the review said these problems were down to a lack of management oversight – with no formal records of this between June and October 2017 and November 2017 and April 2018 – and significant problems with the introduction of a new case recording system.

Looked-after child reviews were carried out, the report said, but it identified a failure on the part of the independent reviewing officer to challenge and escalate concerns about Child T.

Professionals ‘on the back foot’

The last review took place just after Child T was unexpectedly released from custody in June 2018, putting the professional network – which failed to respond beyond what procedure dictated – “on the back foot”.

“From a child-focused perspective, a significant and unforeseen event had just occurred in Child T’s life and his behaviours and conduct were widely known about by a range of professionals,” the review said. “Yet it failed to provoke a proportionate reaction by the professional network.”

The review also identified concerns over possible exploitation of Child T. When he was 15, the disclosure in an initial health assessment that he had had 11 sexual partners from age 14 was not considered in the context of CSE. “This was a missed opportunity… had the child been female and reported this number of partners it may have elicited a different response,” the review noted.

Despite concerns around CSE being raised as part of an August 2016 child in need assessment, there was “no evidence to indicate any follow-through”, it added – though the review stressed there was no corroborating evidence that he was being sexually exploited.

There were also fears Child T was being drawn into ‘county lines’ activity, with him mentioning contact with gangs, being bribed, entering trap houses and having a second mobile he described as his “burner phone”. But the reports were never corroborated.

‘Insufficient coordination’

The serious case review made 19 recommendations, including that the LSCB evaluate arrangements for high-risk adolescents and ensure that there is a multi-agency plan and strategic oversight of each case, and set up a multi-agency exploitation forum.

Many of the points related to children’s services, including ensuring accurate data collection around missing children, return home interviews are of adequate quality, the IRO service’s escalation and challenge policy is fit for purpose and that adequate arrangements are in place for social work supervision.

Sarah Elliott, independent chair of the LSCB, said: “Many individual practitioners, services and agencies worked hard to safeguard [Child T], but did not sufficiently coordinate their efforts at a time of change, uncertainty and increasing risk.

“We have been working with the council together with its partner agencies to develop effective arrangements to meet the complex needs of young people,” she added.

Andrew Parry, portfolio holder for children, education and early help at Dorset council, said the authority had been “working tirelessly to make multi-agency working in Dorset stronger and ensure the mechanisms for sharing information are more robust”.

“We’re particularly working hard to improve support for children at risk of different forms of child exploitation, including giving professionals the tools to assess situations and make sure the right support is offered at the right time,” he said.

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