A flawed special guardianship assessment, made under pressure in a context where reports were rubber-stamped without being checked, condemned a girl to years of “Dickensian” cruelty, a serious case review has found.
In 2015 ‘Megan’, then six, was found to have been subjected to neglect and physical assault by her parental grandmother, who had been granted special guardianship three years earlier, and her household. The grandmother, her son – Megan’s father – and her partner were all subsequently jailed.
The serious case review, one of two published last week by Gloucestershire safeguarding children board, found the assessment of Megan’s grandmother proceeded too quickly despite a Cafcass guardian’s concerns.
“Senior line management was adamant court deadlines were met as [Gloucestershire council] had been deemed inadequate by Ofsted [in 2011],” the review said. It added that the culture within the council at the time “allowed managers to sign off reports for special guardianship cases from social workers they trusted without seeing them, in order to save time”.
The findings are the latest in a long line to raise concerns around inadequate assessments of special guardians – often family members – that subject them to far less scrutiny than potential adopters and foster parents would be.
The number of special guardianship orders (SGOs), which give carers parental responsibility to the exclusion of all others but preserve children’s legal ties with their parents, rose dramatically from 2010-16 in the wake of court judgments ruling that adoption should be a last-resort permanence option. Though over subsequent years the numbers leaving care on SGOs has gone up and down, cash-strapped councils have found special guardianship a convenient pathway, given they are not obligated to offer the same level of support – including financially – as they would in other arrangements.
While guidance around assessments was made more stringent in 2016, a study published last year found they were still routinely being rushed through due to the 26-week statutory timescale for completing care proceedings.
‘Lessons not learned’
Nigel Priestley, a senior partner at Ridley and Hall solicitors, which specialises in kinship care, told Community Care some councils were “still not learning the lessons” of cases such as Megan’s, in terms of ensuring that SGOs are used appropriately.
“Courts, guardians and local authorities have to recognise the strengths of kinship carers – where there is a care order, and they have doubts, they can remove children quickly,” he said. “Make an SGO, and you’re back into all the child protection policies, having to investigate things – and for the child, if they get things wrong, it can be spectacularly wrong.”
In Megan’s case, her grandmother’s assessment took place late in the child’s care proceedings, which were already beyond the 26-week deadline, after the identity of her father was confirmed.
The review noted that Megan’s grandmother, then 37 and with serious money problems, “had no time to assimilate” her role as a grandparent, having a primary school-aged child at the time, and seemed “emotionally flat” during the assessment.
“It is not clear if the [grandmother] fully understood the enormity and permanence of what the SGO involved,” it added. “Professional practice and the actual assessment process was below the standard expected. Practitioners were of the apparent predisposition of keeping a child with the family wherever possible, and believed the SGO would inevitably be agreed by the court, a preconceived practitioners’ assumption, in any case.”
‘No exploration of Megan’s lifestyle’
In the two years after the SGO was made in April 2012, a number of concerns – including around Megan presenting as cold and hungry – were not followed up by early years and education staff.
At one stage the grandmother disclosed to a fostering support officer that she felt she had made a mistake taking on Megan and “found it hard to like her”. But after she declined a parenting course offered by the officer, there was no follow-up, with ongoing support from a local children’s centre focusing on her housing needs.
Poor information sharing, both with children’s services regarding these incidents, and by social workers in relation to Megan’s history, meant there was “no joined up working or exploration of Megan’s lifestyle” with her grandmother.
It was only in June 2015, after Megan was hospitalised with a potential sickness bug and found to have bruising all over her body, that children’s services intervened and removed her from her grandmother’s care.
Megan later told police she had been beaten, tormented – including being made to eat dog faeces – and sexually abused by her grandmother, her partner and her son. The sexual assault allegations were not eventually pursued due to a lack of evidence, but were not discounted by professionals.
‘Appalling’ living conditions
The second serious case review published by the Gloucestershire board last week also concerned a household in which chronic neglect, of four children, three male and one female, was able to take place due to inaction by social workers and others.
The eldest male child also subjected his siblings to “numerous” incidents of sexual abuse over a four-year period, to 2016.
‘Family Y’ had been known to children’s services since 2008, when social workers completed an initial assessment after police attended their home and were “appalled” to find it filthy, including with animal faeces, and with no food in cupboards.
No further action was taken, with the case review finding “no evidence the children were spoken to about their lives”, an outcome that was repeated several times over the next three years.
“[Children’s services] did not take into account the pattern of referrals indicating the children were often dirty, and home conditions were unacceptable,” the review said of a 2010 episode in which another initial assessment was carried out.
In 2012, the children were placed on a child protection plan for neglect, with concerns being raised about the female sibling’s persistent soiling of herself, but this was closed at first review.
‘Lack of urgency’
Over the next four years the girl’s incontinence – which a psychiatrist noted as a possible sign of abuse but did not share – continued, with all the siblings also having persistent headlice and severe tooth decay.
In 2014 “a new social work manager was appointed and in the following two months, home visits still observed poor home conditions, which the children were being expected by professionals to live in with no further action taken”.
After a series of “ineffective” child in need meetings during 2015, the children were eventually placed on a second child protection plan for neglect.
“There was a lack of urgency for the children and a three-month delay in actioning legal planning,” the serious case review said. “The family’s case should have been brought to the attention of the head of service earlier, for scrutiny and oversight of safeguarding action being taken.”
Even after one of the younger siblings made the first allegation of sexual abuse against his eldest brother in May 2016, social workers were slow to react, with a strategy meeting eventually taking place five days later. Following this the eldest sibling was moved to live with this father, while the three younger children were placed in care in November 2016 after the family were evicted from their home.
The serious case review identified a catalogue of practice failings within children’s services, including around supervision, oversight and record management, information sharing and failing to complete multi-agency chronologies.
The children’s voices – as in Megan’s case – went unheard, with social workers and others relying on their mother to make changes. “Clear signs” of sexual abuse were missed, the review concluded.
‘We could have intervened more effectively’
Responding to the reviews’ findings, Richard Boyles, Gloucestershire council’s cabinet member for children’s safeguarding and early help, said the authority had invested significantly in children’s services since 2018, shortly after they were again judged ‘inadequate’.
“It is clear that, with our partners, we could have intervened more effectively at the time these events occurred,” he said of Megan’s situation. “A significant amount of progress has been made since to learn lessons and improve the way we work.”
Boyles said this had included changing the process by which children are placed, “to ensure the best interests of the child remains the focus of everything we do”, improving training around listening to the voice of the child and acting more quickly when disclosures are made.
The councillor acknowledged that the children in Family Y had been put through “unimaginable events” that no young person should experience.
“We know more could have been done, working with our partners, to try and prevent what happened to these children,” he said. Boyles said the council had learned from this case, and had implemented better training for staff on spotting signs of neglect and sexual abuse.