‘Totally inadequate’ post-placement support for special guardian identified in review of child’s murder

Lack of visits and monitoring meant practitioners did not have a proper sense of what life was like for Lilly Hanrahan before 21-month-old’s murder by special guardian’s partner

Image of laptop and magnifying glass (credit: Paweł Michałowski / Adobe Stock)
(credit: Paweł Michałowski / Adobe Stock)

A serious case review into the murder of a 21-month-old girl by her special guardian’s boyfriend has criticised ‘totally inadequate’ post-placement support provided by local authority practitioners.

The lack of visits and monitoring by Birmingham council staff meant they were unable to build up a picture of what life was like for Lilly Hanrahan between her placement with the special guardian in 2016 and her murder by Sean Sadler in November 2017.

However,  the report said the most significant failing was that of a domestic violence perpetrator programme tutor in not informing probation service colleagues that Sadler had resumed a relationship with the special guardian, in September 2017. Had she done so, this would have been shared with children’s social care, and would likely have triggered a section 47 investigation.

Lilly’s parents both misused substances. Following her birth in February 2016, the local authority proposed placing her with foster carers under an interim care order (ICO). However, this was opposed by her mother and maternal grandmother.

The court then made a child arrangements order placing Lily with her maternal grandmother, with an interim supervision order, but an assessment later ruled her out as a long-term care option for Lilly.

The special guardian was also put forward as a carer. Following a positive special guardianship assessment, a child assessment order was made for Lilly to live with her, followed by a special guardianship order (SGO) in September 2016.

SGO assessment ‘as thorough as it could be’

The review, by independent consultant Hilary Corrick Ranger, said the SGO assessment was “as thorough as it could be” considering it had to adhere to the court’s strict 26-week timescale, which “gave no time for reflection or monitoring of the placement prior to a final decision”.

However, Ranger found that the assessment did not explore the guardian’s mental health or relationship history or interview any of her previous partners. Notably, assessors did not interview Sadler, who was the father of the guardian’s eldest child and had been convicted of a number of domestic abuse and other violent offences.

This was because it was thought their relationship had ended about 10 years earlier.

The review also said the assessment failed to explore how the extended family dynamics between Lilly’s birth mother, maternal grandmother and special guardian would impact on Lilly’s life.

However, it concluded that it was unlikely the court would have made a different decision had there not been these deficits in the assessment.

The review was much more critical of the lack of support provided to Lilly and the special guardian after the placement was made.

Following the SGO, with Lilly also placed on a child-in-need plan, the plan was for the social worker to visit the special guardian monthly and hold regular child-in-need meetings. The council also planned to allocate a special guardianship support team worker to the special guardian.

But it said there was no evidence of any visits or child-in-need meetings from the council’s children’s social care services after the special guardianship order was made.

The council allocated a special guardianship team support worker to the special guardian on 18 November 2016, but they closed the case within a month after reporting that the special guardian had failed to respond to offers of help.

The child-in-need case was closed in March 2017.

‘Totally inadequate’ post-placement support

The review said the support post placement was “totally inadequate”.

“Both the case holding team and the special guardianship support team should have been monitoring whether support was taken up,” said the review.

“The lack of recorded visits and meetings should have been picked up by data monitoring and highlighted to managers. Had children in need meetings, home visits, support visits taken place practitioners might have had a proper sense of what life was like for Lilly within this family.”

The review noted that Lilly’s social worker changed following her original child-in-need meeting in April 2016, after which her case was “perhaps seen as lower priority”.

It said: “The original social worker knew all the key players in the case and there was a lack of impetus following that case transfer, especially given the high case load of the second social worker and the view that the plan was in place and driven by the court”

The report also said that the second social worker’s manager frequently cancelled supervision of them due to other work demands.

“It is hard to agree that supervision was effective if it was frequently cancelled, and there is no recorded evidence that supervision was checking that the plan was being followed, nor of reflective and analytical discussion,” the report said.

At the start of November 2017, weeks before Lilly’s murder, her nursery spoke to the special guardian about bruising they had identified. In response, the special guardian mentioned that Lily had been in special care as a baby and queried whether she could feel pain, as a way of explaining the bruising. The nursery accepted her explanations at face value and did not make a referral to children’s social care.

Bruising was also brought to the attention of Lilly’s GP surgery, in October and November 2017, but they did not refer the case to children’s social care.

Improvements made since murder

Andy Couldrick, chief executive of Birmingham Children’s Trust, which took over children’s services in the city from the council in 2018, said he “acknowledged” the shortcomings identified in the report and said improvements had been made since the tragedy.

“In this case, services were involved for six months following the order, and there were no issues or concerns being raised that suggested our involvement needed to continue,” he said.

“When Mr Saddler became reattached to the family, children’s services’ involvement had ended.

“If children’s services had been alerted by probation, or by the services that were made aware of unexplained bruising to the child, then of course children’s services would have become involved once more with the family.

“Since this happened the children’s trust was established and we have continued to improve the robustness and rigour of all of our services, including our support following the making of a special guardianship order.”

Birmingham now offers six months’ post-order support from an allocated social worker to special guardians and reviews their special guardianship order annually.

Penny Thompson, independent chair of Birmingham Safeguarding Children Partnership, which commissioned the review, said the report highlighted “the importance of adult-orientated services sharing information with those supporting children and families, and secondly the value of professionals having open and curious minds”.

“I am assured by the postscript to this report which evidences the actions taken by all agencies following the report’s findings, especially its acknowledgement of the important and positive experience that special guardianship can provide for many children,” she said.

“We have produced a learning bulletin for professionals as a result of this report and I intend to request a meeting with the local family justice board to explore the learning and insights gained from Lilly’s short life and sad death.”

Family response

Lilly’s birth mother, grandmother and special guardian all blamed children’s social care services for her death, the report said.

The mother and grandmother blamed children’s services for the decision not to allow either of them to have long-term care of Lilly, which they believed would have prevented her death.

They also said that children’s services should have continued to monitor and supervise the care of Lilly while she was with the special guardian.

They recommended a national change that all children subject to an SGO should be monitored and supervised for at least three years post the order.

The special guardian similarly said that supervision of SGOs should be made mandatory and claimed that she did not refuse help from the support team.


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14 Responses to ‘Totally inadequate’ post-placement support for special guardian identified in review of child’s murder

  1. Lotte October 11, 2021 at 10:30 am #

    Last week in my team: 4 cases slated for closure because of “non-engagement”, 2 new cases allocated to me even though I’v been trying to say my caseload is already becoming difficult to safely navigate, 5 supervision sessions cancelled as my manager is “needed” elsewhere. Easier to blame other services for not “alerting” social work teams than seriously look at the woeful state we are in though isn’t it? Every social worker will have been in this scenario. This is now routine practice in our teams. Personally, I can’t cope with the despair, the anxiety and the guilt that comes with knowing I fail someone I am supposed to be ‘helping’ every day. Surviving another day is not what a profession should be about. How has glitzy award ceremonies sponsored by recruitment agencies, how has salivating at the prospect of getting an MBE replaced real compassion? Why is there such little outrage that we are overseen by a Regulator that doesn’t know who it’s regulating and for what end? When our managers find more comfort in and prioritise processes over improving lives and safeguarding, when a social work that brushes away every Ombudsman’s censure, every harm and worse to a child or an adult as a “lesson to be learned” becomes the culture, its time to resign. What happened to this child is potentially likely to happen in our teams too. I find that unbearable. So after 23 years I am out. I won’t be missed, my colleagues will still be unsupervised, families will still be blamed for “non-engagement”, PSWs will still ignore what is under their noses, SWE will still flounder, MBEs will still be accepted by “proactive anti-racists”, there will still be a Social Worker of the Year and students and NQSWs will still be bewildered by the reality of how bureaucracy always trumps social work principles. What a waste of good people.

    • TomJ October 13, 2021 at 11:57 am #

      Lotte- I feel you’ve hot the nail on the head when it comes to the across the board issues.

      This review has clearly gone for a ‘blood on his hands’ blame approach for the domestic violence perpetrator programme tutor, something that I thought Munro encouraged us to move away from after the Baby P toxicity.

      I think the big issue with Ombudsmen findings is that they constantly act as though the issue is one in a million, whereas anyone in the know thinks ”I am not in the least bit shocked that post placement support was poor”.

    • Abdul October 16, 2021 at 12:53 pm #

      I’m a statutory child protection social worker with 23 years frontline experience too, having started in the field in 1998. I’m leaving the profession too at the end of this year, as the workload and pressure has become unmanageable and unsafe. I got into this field as I wanted to help family, and make a positive difference. Statutory Social Work in the UK is in a mess, and not fit for purpose, and the only way I have been able to give families a ‘service’, is because I work around 25 extra hours a week for free, & don’t have any life outside of work. I am leaving as I can no longer justify all the long and unpaid hours we do any more, to keep up with the constant, relentless, and unreasonable demands of senior management. The length of the Single Assessment, SWEAT, and Regulation 21 documents (along with the genograms and chronologies) means the time spent doing ‘useless paperwork’, does not allow us the time to do meaningful direct work, and help the families in the way in which they need the help. I’m looking forward to my new life outside of social work; there is so much more.

  2. Linda October 12, 2021 at 11:03 am #

    From one already ‘out’ I feel so sad for you and the silent majority you represent that this is your only option to safeguard yourself. Your years of experience will be missed, by the families you will not be able to support and by your colleagues, not least the NQSW’s who I am sure you have informally guided and supported over the years.
    I hope, like me, you are able to engage in other ways once ‘out’ and use your skills and knowledge to undertake the quality of support you and we so desperately wish we could within Social Care.

    We know that lack of funding and cycling through 4 governing bodies in less than a decade are the critical factors in it being impossible for us to not fail children and families. I wish so desperately that the impact of this could be visible in the mainstream media. The lifetime cost to those children and to society to support them as adults, whether in mental health services or prison, far outweigh the cost of caring now. But while the cost of caring now remains in the “revenue” budget rather than being seen as like a mortgage, a “capital” cost to build a resilient life, the money and resources we so desperately need will never be available. I hope you Farewell, in both the modern and historic meaning of the word.

  3. Elvie October 14, 2021 at 4:23 pm #

    Social Work with families has become a nightmare!

    Thresholds have become so high in certain areas that it’s become less about ‘helping’ and more about enforcing legislation.

    Idealistic theories are bandied about by senior managers with staff being hammered for being insufficiently ‘restorative’ or ‘strengths based’ when they’re fearfully trying to keep their heads above water and one step ahead of a complaint or a sanction or, god forbid, a child for whom they hold responsibility suffering serious harm.

    Social work teams are unhappy, stressful places. I’ve done nearly 30 years and I’d leave tomorrow if I could.

  4. Mary October 14, 2021 at 5:21 pm #

    What a tragic case.

    And how sad it is to hear of experienced colleagues feeling they have no option but to leave such an essential occupation at a time when the need is so great.

  5. Hilton Dawson October 14, 2021 at 9:23 pm #

    Shocking situations & it’s imperative to achieve change
    How many contributors are members of BASW / SWU ?

    • Johnny October 15, 2021 at 7:00 pm #

      I’m not able to call to memory what changes to the system either if the bodies mentioned have made?

  6. Marianne October 15, 2021 at 6:32 pm #

    I have never so sad or so relieved that I made the change to leave the failing nightmare of almost every front line Social Worker’s life.
    I now work with kids prone to violence, in reaction to all they have experienced. Finally I feel like I’m getting somewhere in actually helping children, and not simply ticking another box or meeting another bench mark in ‘good enough’ fire fighting

  7. Carlton October 15, 2021 at 8:04 pm #

    Do you mean the BASW that won’t tell us what it did when black social workers told it white managers were denying them PPE but dishing it out to white social workers?
    That BASW/SWU? Why would we have confidence in a bunch that chooses to ignore racism in pursuit of it’s yappy dog enthusiasm to be loved by the Establishment.

  8. Satwinder Sandhu October 16, 2021 at 9:33 am #

    This is such a failure of a very vulnerable child. Let’s be clear, there is nothing new in these findings. Poor assessment, no support, stretched managers and social workers. Until we truly start to prioritise childhood and keeping children safe there will continue to be cases like this. The social welfare system is failing across the board and unless the Children’s Social Care Review brings about change backed by huge investment nothing will really change.

  9. Annie October 18, 2021 at 11:14 am #

    Is the BASW we are being urged to join the same one that sabotaged and killed dead the possibility of a College of Social Work because of their petty sulk over Unison? The BASW that wants all the toys never mind the rest of us?

  10. Jimmy October 20, 2021 at 12:00 pm #

    BASW is a democratic institution, it is members who make policy so it is really unfair to label public facing officers as mere bureaucrats. They are accountable to members like me. If more social workers joined then we would have a bigger and broader input to policy making. I am glad that BASW gets to meet regularly with SWE and DfE, our power is in our visibility which than gives our views credibility. I am glad if BASW did scupper a College of Social Work because Unison would have had a role. Personally I do not believe unions have a role to play in social work. I think they set up an unnecessary barrier between social workers and our managers who generally are on the same page as us. If I didn’t have to I wouldn’t belong to SWU either for the same reason. We are a profession and we should always act in a professional and be prepared to compromise to promote social work. Instead of taking a pop at BASW why not join and be in the centre of influence.

    • Allison October 20, 2021 at 3:35 pm #

      Oh dear.