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.”
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.