Finley Boden: professionals should have protected baby murdered by his parents, review finds

    Review identifies multiple child protection failings in case of 10-month-old killed by his mother and father 39 days after being returned to their care

    Finley Boden
    Finley Boden (photo: Derbyshire Constabulary)

    Professionals should have protected Finley Boden, who was murdered by his parents 39 days after being returned to their care, a local child safeguarding practice review has concluded.

    Though the inquiry stressed that Stephen Boden and Shannon Marsden were responsible for the 10-month-old’s death on Christmas Day, 2020 – for which they were jailed for life last year – it said practitioners knew that the couple posed a risk of significant harm to him.

    And it concluded that the fateful decision to return Finley and his older sister to their parents’ care was the culmination of multiple safeguarding failings by agencies, though acknowledged that practitioners’ jobs were made harder by Covid-19 restrictions and workforce pressures.

    Parenting assessment ‘offered misleading reassurance’

    The review, commissioned by Derby and Derbyshire Safeguarding Children Partnership, found both Boden and Marsden were known to services before having children. In both cases for mental health and substance misuse problems, and in Boden’s for a history of offending, including in relation to domestic abuse.

    Finley Boden's parents, Stephen Boden and Shannon Marsden

    Finley Boden’s parents, Stephen Boden and Shannon Marsden (photo by Derbyshire police)

    Derbyshire council made their daughter (known as ‘Ruby’ in the review) subject to pre-birth child protection and pre-proceedings plans, under which she would live with Marsden and family members, with restricted and supervised contact with Boden, pending assessments.

    However, the child protection core group subsequently endorsed the couple’s wish to live together with Ruby and ended the pre-proceedings plan, following a parenting assessment that was overly reliant on their accounts of their capacity to care for their child and that received no managerial challenge.

    The assessment “offered misleading reassurance to parents and professionals”, concluded the review.

    Pre-proceedings initiated for second time

    About eight months later, Derbyshire council initiated pre-proceedings again, after Boden was convicted of drug-related offences, reports of cannabis use by the couple, two domestic abuse-related police callouts, concerns about the home environment and instances of the couple avoiding professionals.

    The girl went to live with family members (‘Mr and Mrs Anderson’), however, Boden and Marsden continued to evade professionals, while also testing positive for cannabis.

    A few months later, Marsden disclosed she was pregnant with Finley. However, despite professionals having concluded that Ruby should not be returned to the couple, they took three months to hold a child protection conference in respect of Finley and no pre-proceedings plan was initiated before his birth.

    Care proceedings issued

    Days after Finley was born, Derbyshire issued care proceedings for both children. Following the first hearing, Ruby was placed on a time-limited child arrangements order and interim supervision order to live with Mr and Mrs Anderson.

    Finley was initially placed with the Andersons on an interim care order but, after the second hearing, he was also put on a time-limited child arrangements order and interim supervision order, pending the completion of assessments.

    In line with procedures at the time, Ruby and Finley’s child protection plans came to an end three days after the second hearing, making them children in need.

    Covid impact and concerns over lack of management support

    Shortly afterwards the country went into the first Covid lockdown, significantly curtailing face-to-face contact by all agencies with the family.

    Following the first of only two virtual child in need meetings held during this time, the allocated social worker gave the family court an inconclusive assessment of Boden and Marsden’s capacity to care for their children, with no proposals for final care plans.

    The practitioner (known as ‘social worker 2’), who was inexperienced in statutory children’s social work, told the review’s author that she was unclear what was expected of her and had difficulty in gaining clarity from her managers.

    Another worker raised concerns with the author about the lack of management support for inexperienced staff in Derbyshire at the time.

    The review said that, even without the complexities caused by Covid, producing a good-quality assessment, particularly with no established relationship with the parents, was a complex task. It required sufficient time, input from partner agencies and, for an inexperienced practitioner, “active managerial support”.

    No visits or meetings for six weeks

    Following a second virtual child in need meeting, at which there was no evidence long-term planning was discussed, the social worker was off sick for six weeks, during which time there were no social work visits to the children or parents and no child in need meetings held.

    Before social worker 2’s return, an agency worker (‘social worker 3′) was asked to carry out an updated assessment. Based on outdoor contact sessions and time spent with Marsden and Boden, she concluded that, with time and support, they could make changes, and recommended the children’s phased rehabilitation, over six months.

    On her return to work, social worker 2 carried out an unannounced visit to Marsden and Boden but was refused access and greeted with hostility. She then had a meeting with her practice supervisor, in which they discussed the parents’ hostility and dishonesty, but not care planning or possible reunification.

    Plan for reunification 

    However, Derbyshire’s final evidence to the court recommended a plan for reunification over four months, alongside 12-month supervision orders for Finley and Ruby and child arrangements orders with Mr and Mrs Anderson. This was signed off by a team manager and head of service at the council.

    The review found that the plan was strongly influenced by social worker 3’s positive assessment that the parents had “engaged well with services and demonstrated their ability to meet all the needs of the children”.

    However, the evidence for this conclusion was “weak,” said the report, and the plan also had the disadvantage of there being no legal oversight over decisions on where the children would live permanently.

    The guardian’s view

    The Cafcass guardian in the case had met the parents only once, with all other contact with Marsden and Boden, the children and family members being virtual, because she was shielding.

    She accepted Derbyshire’s view that the parents had made “good progress” and had no objection to the children being returned, but wanted long-term decisions about them to be taken during proceedings, to ensure they were signed off by the court.

    So, she proposed reducing the reunification period to six-to-eight weeks and extending proceedings, meaning the court could make final orders in favour of Mr and Mrs Anderson should rehabilitation prove unsuccessful.

    What the court decided

    The court agreed with the guardian’s proposed timescale and against the council, and also rejected the Derbyshire’s call to make an order requiring Marsden and Boden to undertake regular drug testing, a point on which the guardian was neutral.

    Social worker 2 said she was “disappointed and frustrated by both outcomes”, feeling that a longer period of rehabilitation was in the children’s best interests and that not ordering drug testing removed a reliable source of information for the council with which it could challenge the couple.

    Despite the lack of an order, the guardian believed that drug testing would continue. In conversation with the author, she attributed her view to her inexperience as a guardian and difficulties managing remote proceedings.

    The parties agreed a transition plan, under which the parents would have increasing levels of contact up until the children’s full return, and would receive weekly unannounced visits by children’s social care.

    Children ‘not seen in parents’ care after court hearing’

    However, by the time of the subsequent child protection conference, around four weeks later, the children had not been seen by practitioners in their parents’ care, despite the fact they were, by then, primarily living with Marsden and Boden.

    The conference did not include Marsden, Mr and Mrs Anderson – despite them having parental responsibility under the child arrangements orders – or representation from substance misuse services.

    The social worker’s report to the conference was optimistic, with the only issues noted being uncertainties over the parents’ drug use. The resulting child protection plans reduced the frequency of visits set out in the transition plan.

    999 call 

    A week later, police responded to a 999 call at Marsden and Boden’s house, reportedly due to someone banging on the door to collect a drug debt owed by Boden.

    However, though the officer who attended gleaned from Marsden that there were children in the house, they were not alerted to the fact that there was a ‘flag’ at the address to indicate the children were the subject of child protection plans.

    As a result, the children’s details were not recorded and social care was not informed.

    “In the circumstances of this case, that gap was significant,” the review concluded.

    Finley Boden in cot

    Finley Boden (photo: Derbyshire Constabulary)

    ‘Inadequate’ safeguarding practice

    Very shortly after, the children returned to their parents’ care full-time.

    The review said that the criminal trial into Finley’s murder revealed how little professionals knew about the last few weeks of his life, but concluded that “safeguarding practice during that time was inadequate”.

    Of two health visitor visits that should have taken place during this time, just one occurred.

    Of six social care visits that should have been carried out, only four were attempted. On one occasion, there was no answer from the parents and on the other three, issues arose that warranted further inquiry, but necessary actions were not taken.

    On one occasion, Finley had a bruise to his head – which the parents said had been caused by a toy thrown by Ruby – on another, he was found sleeping unattended on the sofa and on the third, the social worker could not see him because Boden said he had Covid symptoms.

    The social worker and health visitor communicated too infrequently to identify issues of concern and there was only one child protection core group conference call during the period. The health visitor was absent for this and information shared seemed to reinforce the perception of an improved family environment but without objective evidence to back this up.

    Six weeks after his return home, Finley was dead, with a post-mortem finding him to have had injuries that were “abusive and inflicted”. Ruby was unharmed and returned to the Andersons’ care.

    Criticism of parenting assessments

    While stressing Boden and Marsden’s responsibility for Finley’s death, the review concluded that “professional interventions should have protected him”, with agencies’ failure to do so the culmination of several previous decisions, events and circumstances.

    A key lesson from the inquiry was practitioners’ over-reliance on parental self-report and their over-optimism about Marsden and Boden’s capacity to care for their children, in the two parenting assessments during the review period.

    For example, in the second assessment, which underpinned the council’s care plans for the children, too much weight was given to the parents’ expressed intentions to reduce their cannabis use.

    “Most strikingly, parents were not asked to explain what went wrong when they were caring for Ruby, and so no insight is offered as to how they expected to avoid similar difficulties in future,” the review added.

    Recommendation and response

    The review recommended that Derby and Derbyshire Safeguarding Children Partnership (DDSCP) audit recent parenting assessments to evaluate their quality and evidence of management scrutiny.

    In response, DDSCP said the council had set up a dedicated parenting assessment team and audits had shown an improvement in the quality of these assessments.

    Ineffective use of pre-proceedings

    The review also criticised the council’s use of pre-proceedings, particularly on the second occasion Ruby was subject to these after she moved to live with the Andersons. Though the council concluded care proceedings should be issued because of Marsden and Boden’s unwillingness to engage, “no sustained progress was made to that end, however, during most of the six months which followed”.

    There was also an “attendant lack of urgency in bringing care planning for unborn [Finley] into the legal framework”. This meant that, by the time it issued care proceedings, the council was not adequately prepared to put permanence plans before the court, which led to pressures to complete assessments that should have been carried out earlier.

    Recommendation and response

    The review recommended that DDSCP require the council to provide evidence of the improved effectiveness of pre-proceedings work with children and parents, including evidence of appropriate diversion from care proceedings and, where this was not possible, the securing of timely permanence plans.

    DDSCP said there had been such improvement with an Ofsted inspection of the council last year finding that “effective, authoritative social work in pre-proceedings and care proceedings is resulting in timely permanence plans for children”

    ‘Very limited’ multi-agency work

    The review also concluded that “multi-agency work within care proceedings was very limited and that this was detrimental to Ruby’s and [Finley’s] welfare and safety”.

    When they were moved from child protection to child in need plans when they were made the subject of interim supervision orders, some agencies interpreted this as a “stepping down” that meant reduced involvement in the case. This was despite a court having found that the threshold of significant harm had been met for both children.

    Local multi-agency procedures in Derbyshire now require child protection plans to continue where children are the subject of interim supervision orders, until final orders are agreed. However, the review said for this to make a difference in reality, there needed to be a change in culture such that partner agencies did not see court work as a local authority task.

    Reunification risks ‘not adequately understood’

    The review said the inherent risks in returning Finley and Ruby to their parents were “not adequately understood”, given the “very limited evidence” of change since they were found to not be caring for their daughter sufficiently well.

    Increasing the likelihood of a successful reunification would have required high levels of support and challenge to the parents, however, the transition plan did not meet these criteria.

    Professionals involved with the family were not consulted prior to the reunification plan being put to the court and were unaware of the details of the transition plan. There was also no comprehensive package of support and it was not clear what concerns would have triggered a reversal of the reunification plan.

    Recommendation and response

    The review recommended that DDSCP should audit cases where children were returned to parents in pre-proceedings or during proceedings and, where possible, evaluate outcomes for children and families after six and 12 months.

    In response, DDSCP said there had been improvements in reunification work, with the 2023 Ofsted inspection concluding that “careful, phased planning ensures that most children who return home to their parents do so successfully and sustainably”.

    Workforce issues compounded by Covid

    The review also highlighted the fact that the social workers and guardian involved in the case were inexperienced and reported “heavy workloads”, which meant they faced significant difficulties meeting court deadlines.

    These difficulties were “compounded by the challenges of living and working during a pandemic and practising in the context of public health measures”.

    The report acknowledged improvements since the time covered by the review, with a reduction, from 36% to 25%, in social worker vacancies at the council from 2019-23, and 36 more permanent practitioners being in frontline practice. It also reported that workloads had reduced at Cafcass.

    The review also praised the “significant resource” that the safeguarding partnership had invested in improving child protection practice with babies, based on findings from other practice reviews. In its 2023 inspection, Ofsted found this “has led to the development of positive initiatives with health partners to ensure strong oversight of vulnerable parents during pregnancy and post-birth”.

    Steps taken to improve practice and systems

    Giving the safeguarding partnership’s response to the report, independent chair and scrutineer, Steve Atkinson, said: “I offer my sincere condolences to Finley’s family and apologise on behalf of the partnership for what happened.

    “The partnership agencies took early steps to improve systems and practices, responding quickly to an immediate review of Finley’s death and the circumstances in which it took place.

    “In accepting in full the recommendations of this review – commissioned by the partnership, completely independently of Derbyshire and the organisations involved – agencies will take the additional action necessary to further reduce the risk of a repeat of a similar incident.”

    The partnership has published a report detailing progress made since the period covered by the review in addressing its findings.

    Cafcass ‘profoundly sorry’ but highlights parents’ deception

    In a statement on the findings, Cafcass said it was “profoundly sorry” that it and partner agencies were unable to prevent Finley’s death.

    It said that, as a result of Finley’s murder, it had strengthened the management support and supervision of family court advisers and guardians in cases where a local authority was proposing to return a child to parents or carers where there has been known or alleged abuse or neglect.

    In relation to the family court’s decision to follow the guardian’s recommendation on the timeframe for Finley’s return home, Cafcass said “it was not possible to say whether a longer transition plan would have prevented his death”, based on what was known at the time.

    It added: “What led to his death was the ability of Finley’s parents to deceive everyone involved, about their love for him and their desire to care for him. No one could have predicted from what was known at the time that they were capable of such cruelty or that there was a risk that they would intentionally hurt him, let alone murder him.”

    What are your thoughts on the current models of child and adult safeguarding practice reviews?

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    13 Responses to Finley Boden: professionals should have protected baby murdered by his parents, review finds

    1. David March 29, 2024 at 1:26 am #

      Yet again there an issue about caseload demands, not just for Social Workers but also for other professionals, eg Health Visitors, charged with the safeguarding of vulnerable children, and the lack of management support. Need for greater investment.

    2. Abdul March 29, 2024 at 7:24 pm #

      Very sad for this poor baby who died, who never had a chance. The blame entirely for this is on the abusive parents, who perpetrated this criminal abuse and murder. Also, to blame for this is the Government for the seriously lack of inadequate funding and staffing, which does not allow statutory social worker’s to do their job to safeguard and protect the vulnerable children, and also shame on senior management for not speaking out and lobbying Government, and allowing this shameful situation to continue. It’s the same old story, of Social Worker’s not being able to do their job’s due to chronic paperwork and endless reports, chronic workloads, and overwork. The poor social worker could have had several similar cases on her caseload, and not enough time or hours in the day or night to deal with it all. I worked in statutory for 26 years, and was working a 70+ hour work, paid for only 35, chronically overworked, and fatigued all the time. Not worth it, life is too short, glad I got out of it.

      • Tracy April 2, 2024 at 1:23 pm #

        I agree with all of this. It’s become a fairly impossible task for staff. Knowing what people will do to others, including their own children, is not always possible. When social workers remove children they’re demonised then too.

    3. Anna B March 30, 2024 at 11:52 am #

      I wonder how much of the inaction, missed visits, lack of joined up working, late reports etc were indirectly or directly caused by underfunding, understaffing, staff sickness and lack of provision and training? The review looks at the face value issues and missed opportunities but how much of this could have been prevented if there were adequate staffing levels, lower caseloads and less pressure? And perhaps this could have prevented the social worker sickeness and use of agency workers resulting in inconsistency.
      Don’t get me wrong, if an individual is neglectful in their practice this should be highlighted, but at what point does all the failings point to a failure in the system and funding rather than the failings of individual practitioners every time?

      I am sure this will all improve with the plans to move child in need cases to unqualified workers on even less pay and training……

    4. David March 30, 2024 at 3:58 pm #

      Have managers allowed social workers to do their job?

    5. margaret wade March 31, 2024 at 5:13 pm #

      This has been the case for many years . The whole thing is sickening Government are not bothered about these poor little children, Under staffed and underfunded.. No one takes responsibility….The staff must be so distressed as they get to know the familys during their work… Hope things change for the better very soon, ,as it is heart breaking to hear of these beautiful children being tortured and murdered..

    6. David April 1, 2024 at 3:57 pm #

      The mindset of managers needs to change so that they respect the importance of the long and hard fought for 37 hour week as a very important means of supporting workers in any job.

    7. Libby April 1, 2024 at 4:47 pm #

      Things can not continue in the same negative pattern. More social worker should be trained, emphasis should be laid on communication within the professionals and fund should be release if the social system is to be a success, progress and strive.

    8. Hilary Searing April 2, 2024 at 11:59 am #

      I agree with Libby that fundamental change is required. The social workers in this case were ideologically opposed to being suspicious, even when the circumstances required it. Their ‘safeguarding’ approach meant they failed to see the dangers from potentially violent parents before it was too late.

      In 1962 the article by Kempe on The Battered Child Syndrome had a huge influence on subsequent thinking about about child abuse but it seems that this concept has been forgotten. See my article on The Prevention of Baby Battering

    9. Norham April 2, 2024 at 12:17 pm #

      Yet another DCS hiding behind an Ofsted judgement. When will the sector wake up and recognise regulatots can only undertake a snapshot of an authority’s performance and not guarantee all children are safe. The local authority should have it’s own internal mechanisms for determining that. Regulators should move in when concern are raised rather than try and inspect everyone regularly. MA teams advocated by Mcallister/Wood are not the solution either – we’ve been there before and it leads to two tier provision at a local level. Neither of those incumbents have been responsible for providing day to day supervision of social workers and therefore have a limited understanding of what’s really going to make a difference . Invest in social workers/Team Managers and keep caseloads down to 5-8. Costly but more effective than these relentless ,repetitive and sadly meaninglessness reviews saying the same things.

    10. Pauline O'Reggio April 4, 2024 at 7:29 pm #

      My heart goes out to Finley may he rest in peace.

      There is no doubt both parent have failed their son whom they should have protected.

      What needs to be recognised,parents can be mannupative and will attempt to collude with professionals they consider have more power.When you carryout an assessment parents are also assessing you they are assessing what you know,your presentation,some parents will attempt to strike up a friendly relationship leading the social worker to lower their guard this will be used against the worker in court to discredit them.

      High case loads and untimely allocation of cases impacts the social workers ability to provide adequate assessments to enable relevent safeguards for the child.

      Assessments are not about who can type up an assessment in one or two days,it is not about who knows their way around the IT system,which in my view appears the priority.(you can not be an expert at everything).

      Social workers are trained in working with vulnerable children and families without support,high case loads,inappropriate allocations, meaning less supervision just going through the motions without direction and a lack of support impacts the work.

      Assessments reports impacts decision making,they require observations frequent visits one/ two visits does not inform such an important report. Analysis, information gathering from your observations and analysis of the child’s lived experience all of which inform decision making.

      Assessments are continual risk assessments,they require using genogrames and hypothesising.They are indepth reports.In my view we have lost this practice, is this a lack of resources,how cases are allocated,management decisions or attitudes?

      This needs addressing to prevent more children suffering significant harm or looseing their life all of which impacts how the profession is viewed by the public and other professionals.

      Perhaps social workers need more training about parents who are intimidating to avoid engaging with social workers,parents who mannuplate by being over friendly,display violent behaviour towards social workers all of which can be behaviour to keep social workers at arms length.Many chances need to happen blaming covid and social workers only mask the issues.

      These are my experience.

      • frustrated April 8, 2024 at 8:56 pm #

        My experience was an inexperienced ambitious manager forgot how manipulative parents can be. I expect she is still practising I am not.

    11. Pauline O'Reggio April 4, 2024 at 11:19 pm #

      Meetings should not be viewed as time consuming.As a group of professionals you are making decisions which will be life changing for the çhild, who is dependant on professionals having their best interests at all stages.

      Each professional should be bringing new information to the meeting’s that should also include the child’s guardian.I am aware they act as an independent agency, however information sharing should not just be down to the social worker,the childs guardian should be making thier own enquires which includes more than one visit and not fully replying on the social workers assessment.

      If meetings are addressing the same issue’s and there is no movement then should the question be why not?

      When it comes to Safeguarding a child, how can a process be time consuming is it not for the professionals to ensure it is of value to the child’s plan and safeguarding the child?
      it is the profesdionals who should ensure every aspect as been covered has this is safer for the child.

      Perhaps this is an area which needs addressing.

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