Points and recommendations raised in serious case reviews about information sharing.
SCR in respect of Keanu Williams, 2013 Birmingham. Died from multiple injuries. Mother Rebecca Shuttleworth convicted of murder.
The main finding of the Review Overview Report, when all the information had been merged and analysed, was that professionals in the various agencies involved had collectively failed to prevent Keanu’s death as they missed a significant number of opportunities to intervene and take action. They did not meet the standards of basic good practice when they should have reported their concerns, shared and analysed information and followed established procedures for Section 47 Enquiries (child protection investigations) and a range of assessments including medical assessments and Child Protection Conferences.
The SCR Panel was in agreement that Keanu’s death could not have been predicted. However, in view of the background history of Rebecca Shuttleworth and the older Siblings including the lifestyle and parenting capacity of Rebecca Shuttleworth and the vulnerability of Keanu in Rebecca Shuttleworth’s care; it could have been predicted that Keanu was likely to suffer significant harm and should have been subject of a Child Protection Plan on at least two occasions to address issues of neglect and physical harm.
The Overview Author and the Serious Case Review (SCR) Panel concluded that there were a number of significant missed opportunities to provide services to the three children and to assess their needs within a collaborative multi-agency framework.
The review concluded that:
No services were provided which had a focus on improving the care for and circumstances of Keanu outside the nursery service itself. The staff in the nursery did not proactively exchange information about Keanu internally and had no contact with any other professionals or agency. The interactions described with Rebecca Shuttleworth appear to be ‘chats’ initiated by Rebecca Shuttleworth when she wanted to talk to someone. There is no sense of direct or purposeful work being undertaken in accordance with a plan for Keanu.
Keanu was one among fifty children being looked after at the nursery.
Learning point:
In many ways the ‘rule of optimism’ seemed to be affecting the professionals. In this case the longstanding use of the same nursery by Rebecca Shuttleworth’s extended family and by Rebecca Shuttleworth herself (she had attended it as a child) may have led to a familiarity which clouded the views of the professionals of Rebecca Shuttleworth’s capacity to care for Keanu. Rebecca Shuttleworth, when interviewed referred to the staff as ‘more like friends’.
There was also no purposeful or planned interventions designed to improve outcomes for Keanu.
Child K Southampton 2013 – boy aged 7 years, died from head injuries in 2011. The child and his family were known to a number of different services as a result of repeated incidents of domestic abuse and long term concerns about the safety and welfare of the children, particularly child K.
It is now nearly three years since the death of Child K, and the review heard of many changes in the design and delivery of services in Southampton since then. Nonetheless there were serious systemic and also individual failings, which were found in many of the organisations contributing to this review. Staff at the pre-school and the school failed to make child protection referrals on a number of occasions despite explicit evidence of injury and inappropriate sexualised behaviour. A school nurse received a report that Child K had been hit by his “father” but took no further action. A health visitor saw possible injuries soon after a child protection investigation but did not follow this up. A child mental health professional and a Cafcass officer failed to follow up indications of non - accidental injury. The Serious Crime Review conducted by Hampshire Constabulary after the death of Child K found serious weaknesses in the management and resourcing of the police investigations carried out at the time of Child K’s death. Managerial oversight across all these organisations was inadequate.
The domestic abuse of Ms L lies at the heart of these events. It will have profoundly affected Child K and the other children but it also served to sidetrack the agencies. Not only did they lose sight of their principal responsibility for safeguarding children, they also lost alertness to the possibility that Ms L was both a victim and a perpetrator of abuse. The fact that she was a victim clouded professional judgment and obscured the need systematically to explore the relationships within the family. Although the scale of domestic abuse was at times recognised, its consequences for the family were not.
The extent to which Child K was abused emerges strongly in the reports submitted by his pre-school and his school. Sadly the failure of those establishments to respond appropriately to child protection concerns can be seen just as clearly.
7.3.2 The pre-school manager (who is also the establishment’s proprietor and identified lead officer for child protection) had noted that Ms L’s lifestyle was “chaotic”. Ms L often presented as nervous and, in the words of the manager
“always came across as a frightened rabbit”.
However the manager felt that there were no concerns about Child K’s behaviour. It is hard to reconcile those observations with what we know of the harm he had already suffered throughout his life.
7.3.3 In June 2008 Child K had bruising which was brought to the attention of staff by Ms L. The manager took no action. Then, on the last day of June, he was seen to have
“facial bruising, black eyes, a scratch on his forehead and purple markings on his right lid”.
Ms L prompted the child to say that the injuries had been caused by Mr C. That may be true but she was now in the relationship with Mr X. It may be that Mr X caused the injuries, or that Ms L herself did, and she was covering this up and aggravating her dispute with Mr C, by coaching Child K into what to say. In any event, whoever inflicted these injuries, the manager did not report this to CSC. She left a message for the social worker to call her but took no further action.
7.3.4 This was a grossly inadequate response. Workmen, without any professional background, saw what were probably the same injuries and recognised the need to ensure that they were investigated, while this childcare manager, with a lead responsibility for safeguarding, failed to do so. The IMR offers no explanation for this. The fact that neither of the June incidents led to appropriate action is extremely concerning. The second occasion was Child K’s last day at this establishment which aggravates those concerns. A potential structural weakness – that the same person was the proprietor and the manager and the lead officer for safeguarding – was not addressed.