Failures of Intervention where children die

To a considerable extent Children's Social Services are allowed to get on with things without scrutiny in the hope that they will protect children.

This page is a link to stories about cases where things have gone wrong and children have died. This can be where children in care have died or it could be when children have died (often at the hands of their parents) when intervention could have helped.

In practise no system can be perfect. However, the system we currently have is so spectacularly bad that it intervenes when it shouldn't and fails to intervene when it should.

2006
September
6th September - Tahla Ikram returned to parents and tortured to death.
November
November 18 Leticia Aalayah Wright died in Huddersfield 2007
January
January 2007, Hackney, two children killed by schizophrenic mother who local authority forced father to allow children to stay with
July
July 2007 Salma El Sharkawey a girl in the care of Camden who should have been with one of her parents.
29th July 2007 Anna Hider - Portsmouth - girl in care of council drowns.
Rikki Neave,Nov 94, Peterborough Dylan Lockerbie 1995,also other son he killed in 1988,Dumfries and Galloway Lauren Creed 1997,Norfolk,(3rd child killed brought to SS attention in 3 years)they say lessons have been learnt and inquiry undertaken!!) Alijah Ismail.Oct 1998,Harrow Kristian Bebbington,1999,Norfolk John Smith,Dec 1999,Brighton and Hove Kennedy Mcfarlane May 17,2000-Dumfries and Galloway Lauren Wright May 2000, Norfolk Victoria Climbie,Feb 2000,Haringay Chelsea Brown, March 2000,Derbyshire Melissa Stricken,Oct 2001,Blackburn Caleb Ness,Oct 11 2007 edinburgh Ashley Chadburn,Dec 2001,Sheffield Ainlee Labonte,Jan 2002,Birmingham Carla-Nicole Bone,May 2002,Aberdeen Perrin Barlow,July 2002,Plymouth Jordan Reid, July 2002, Birmingham Jasmine Galyer,Feb 2003,Lincs Chloe Fahey,June 2003,Manchester Tyrell Rowe,17 Oct 2003,Hackney Toni-Ann Byfield,Sept 2003, Birmingham Scott Slipper,August 2004,Swindon Ukleigha Batten-Froggatt,2005,Camden Courtney Crockett,Jan 2005,Manchester Kimberley Baker,April 2005,Swindon Aaron Gilbert,Swansea,May 2005 Danielle W Newcastle,2005 Aaron O'Neil 2005,Newcastle Alexanda Gallon,2005,Newcastle Deraye Lewis,Jan 2006,Milton Keynes,Beds Leticia Aalayah Wright,Nov 2006,Kirklees Subject: list of children killed >> >> Rikki Neave,Nov 94, Peterborough,http://www.peterboroughtoday.co.uk/ViewArticle.aspx?SectionID=1783&ArticleID=892413 Dylan Lockerbie,March 1996,Dumfries and Galloway,http://news.bbc.co.uk/1/hi/scotland/2163281.stm>> Since then, a review of the case judged that a mistake was caused by weaknesses in service arrangements and an error of judgement. However, the review did not conclude that Dylan's death would necessarily have been avoidable. Disciplinary action The council said "appropriate action" had been taken under its disciplinary policy but refused to reveal further details. Procedures now were different to those in 1996, it added. At a news conference on Wednesday, Keith Makin, chairman of the child protection committee, said: "I am confident that the way we deal with child protection and the links between agencies are much stronger and more secure now." In May 2000, after the murder of three-year-old Kennedy McFarlane in Dumfries and Galloway, the council commissioned Dr Helen Hammond to come up with an action plan for health and social services. The Hammond Report, published in February 2001, also reviewed the procedures put in place after the death of Dylan Lockerbie and concluded they had not been carried out properly. >> Lauren Creed 1997,Norfolk,(3rd child killed brought to SS attention in 3 years)they say lessons have been learnt and inquiry undertaken!!) The National Society for the Prevention of Cruelty to Children (NSPCC) has unveiled proposals for reform following the death of Lauren Wright. One member of staff has already resigned as a result of the case. Officials from the department of health have ruled out a public inquiry into the case. >> >> Alijah Ismail.Oct 1998,Harrow,http://news.bbc.co.uk/1/hi/uk/464226.stm Mary Ney, director of social services, said lessons would be learnt from the case and an action plan would be drawn up. She added that procedures existed which would have protected Aliyah, but staff needed to have "sufficient tenacity" to follow them through. The report, which makes 18 recommendations and four key points, says staff need better training in communication skills and calls for a better system for sharing information on at-risk children. The summary report does not give details on individual blame or how staff should be disciplined in such cases. Two social workers involved in the case have been suspended and are charged with serious misconduct. >> >> Kristian Bebbington,1999,Norfolk, Four-month-old Kristian Bebbington was on the department's "at risk of neglect" register when he died in 1999. >> >> John Smith,Dec 1999,Brighton and Hove,http://news.bbc.co.uk/1/hi/england/1613997.stm An independent investigation into the case has criticised the adoption assessment process and some of the social workers and other professionals involved in the case. It claims more vigorous checks would have revealed the couple were not suitable to be adoptive parents. >> >> Kennedy Mcfarlane May 17,2000-Dumfries and Galloway ,http://news.bbc.co.uk/1/hi/scotland/1196329.stm The report said Kennedy'd death could have been prevented An independent inquiry has concluded that the death of a three-year-old girl "could have been prevented". But it refused to apportion blame to health and social work officers saying that "her violent death could not have been accurately predicted". The independent inquiry, which was carried out by consultant paediatrician Dr Helen Hammond, said the child's life could have been saved if Dumfries and Galloway Council implemented its full child protection procedures. But it refused to blame any one individual or agency for her death. In her report Dr Hammond said: ""I do not believe that anyone could have predicted the sudden and violent death which occurred on May 17 (2000). "However a number of opportunities to identify the extent of the risks to Kennedy and for effective intervention had arisen as the case unfolded. Dumfries and Galloway Council's Director of Social Work, Keith Makin, said the report's recommendations had been taken on board. "We are at the point now where we are confident that our child protection services are as protective as they can be," he said. He said that a practitioner and management staff were being disciplined as a result of the inquiry but refused to name them or confirm the numbers involved. He said one person had been moved to a post where they were not making "operation decisions" and confirmed that the decision had been taken at a "fairly senior management level". >> >> Lauren Wright May 2000, Norfolk,http://news.bbc.co.uk/1/hi/england/1574622.stm Director of Norfolk County Council social services, David Wright, said that if existing procedures had been followed in Lauren's case she would "in all probability be alive today". On Tuesday its director said he would not resign. Mr Wright said: "I don't think my resignation or that of any of the senior managers will protect any children in Norfolk. "It will make a very difficult situation even less stable and less safe for children." Lauren is the third child brought to Norfolk social service's attention to die in the past four years. Officials from the department of health have ruled out a public inquiry into the case. >> >> Victoria Climbie,Feb 2000,Haringay,http://news.bbc.co.uk/1/hi/uk/5003334.stm >> >> Chelsea Brown, March 2000,Derbyshire,http://news.bbc.co.uk/1/hi/uk/1206019.stm When the pair were both received life sentences in January, there were calls for an urgent review of the social service system to ensure it could never happen again. Hilary Owen, the author of an independent report into the case, told a press conference on Tuesday that Brown had been able to mislead professional about the cause of many of Chelsea's injuries. She added: "The death of any child is always a cause for great sadness and the circumstances surrounding Chelsea's death are particularly tragic. "There was increased concern about Chelsea in the time she was living with her parents and removal was an active consideration in the last few weeks of her life." Mr Buckley refused to discuss whether the principal social worker in the case, Norma McDevitt, would be disciplined. Authorities are agreed that the many lessons learnt from the loss of Chelsea Brown and Anna Climbie should this time guarantee that no child dies in such tragic and violent circumstances again. >> >> >> Melissa Stricken,Oct 2001,Blackburn,http://archive.thisislancashire.co.uk/2006/11/8/941792.html >> >> Caleb Ness,Oct 11 2007 edinburgh,http://www.fassit.co.uk/caleb_ness.htm >> >> Ashley Chadburn,Dec 2001,Sheffield,http://www.telegraph.co.uk/news/main.jhtml?view=DETAILS&xml=/news/2003/05/10/nhipk10.xml In his report Roger Thompson, a former director of the NSPCC, makes 26 recommendations aimed at preventing a repeat. "There was not, in my view, a full and proper assessment of the mother's parenting capacity," he said. The chairman of the Area Child Protection Committee, which commissioned the report, said that the committee had already implemented half of the recommendations But the independent report concluded the tragic death of Ashley Chadburn, from Frechville, Sheffield, could not have been avoided. >> >> Ainlee Labonte,Jan 2002,Birmingham,http://www.careworld.net/Articles/q402/dec/Social%20workers%20paralysed%20by%20fear.htm The report made a series of recommendations for better training in child protection for all services coming into contact with families. Kathryn Hudson, Newham's director of social services, said a new action plan was being implemented to try to prevent a similar incident, but no member of staff had been disciplined over Ainlee's death. "No single individual is held accountable for the death of Ainlee," said Mrs Hudson. She said social services in the borough - and across the country - faced major problems in finding and keeping child protection staff. >> >> Carla-Nicole Bone,May 2002,Aberdeen,http://www.fassit.co.uk/carla_nicole_bone.htm THE family of murdered infant Carla-Nicole Bone last night condemned as a "whitewash" a report clearing care workers of any blame for her death. The grandparents of the 13-month-old girl said they were "appalled" by the findings of an independent investigation into her death at the hands of her mother’s boyfriend. Although the report said that care workers should learn lessons from the case, it concluded they could not have predicted, nor prevented, Carla-Nicole’s murder. Mrs Berry said: "This report is nothing more than a cover-up. Had the social services acted when we contacted them, I am convinced Carla-Nicole would still be alive today. >> >> Perrin Barlow,July 2002,Plymouth,http://news.bbc.co.uk/1/hi/england/devon/4534967.stm Plymouth Council has won a High Court battle to prevent an inquiry into its role in the death of a baby whose mother was jailed for cruelty. A judge quashed a coroner's call for an investigation into the role of "systems neglect" in the death of nine-month-old Perrin Barlow. South Devon Coroner Nigel Meadows had said the inquest should cover the possible role of child protection agencies, citing his right to life under the European Convention of Human Rights. But Mr Justice Wilson said such an investigation could only be triggered if agencies had tangible grounds for believing Perrin was in immediate danger. >> >> Jasmine Galyer,Feb 2003,Lincs,http://news.bbc.co.uk/1/hi/england/humber/3420573.stm A case review is now under way at North Lincolnshire social services after it emerged a social worker visited the family in January 2003. >> >> Chloe Fahey,June 2003,Manchester,http://www.manchestereveningnews.co.uk/news/s/61/61731_tears_for_tragic_chloe.html As social services bosses began an investigation, >> >> Tyrell Rowe,17 Oct 2003,Hackney,http://news.bbc.co.uk/1/hi/england/london/3211791.stm On Friday Judge Anthony Morris criticised the council for not making public an internal investigation into the death. 'Lack of protection' "I find it regrettable because the purpose of such an investigation must be how such failures occurred and to prevent them happening again," he said. The Area Child Protection Committee is concluding its investigation. Recommendations will be implemented by the respective agencies. "Appropriate action will be taken as required if individual failings are identified." >> >> Ton-Ann Byfield,Sept 2003, Birmingham,http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=260199&in_page_id=1770 Harry Fletcher, assistant general secretary of the union for family court and probation staff, Napo: "One [West Midlands Cafcass] manager was supervising 40 staff who themselves were under pressure to increase their caseloads by 25%. This situation is not acceptable. If child protection services are to be effective, there must be sufficient numbers of trained and dedicated staff. There will be more tragedies unless the structural issues of resources and training are finally addressed by ministers." http://www.guardian.co.uk/child/story/0,7369,1206147,00.html >> >> Scott Slipper,August 2004,Swindon,http://www.thisiswiltshire.co.uk/misc/print.php?artid=844455 A review into his death, which was disclosed to the inquest, stated there was a chance Scott's death could have been avoided. The report made several key recommendations to stop the failings which may have contributed to Scott's death from happening again. Swindon coroner David Masters demanded he was kept up-to-date with the implementation of the recommendations. Mr Slipper said: "Nobody knows what we went through ourselves. We were given no assistance from any authorities. We just needed some support because of what he was doing. Our family has been let down by social services. If the recommendations in the report were there in 2004, there's a chance Scott would still be with us." >> >> Ukleigha Batten-Froggatt,2005,Camden,http://mentalhealthorguk.site.securepod.com/profilenews.cfm?pagecode=NENE&areacode=NEWS_mhf&id=9717 Following Ukleigha's death, the council launched an inquiry into the conduct of the multi-agency child protection team responsible for her safety. >> >> Courtney Crockett,Jan 2005,Manchester,http://www.manchestereveningnews.co.uk/news/s/191/191390_killed_at_the_hands_of_mums_new_boyfriend.html >> >> Kimberley Baker,April 2005,Swindon,http://www.gazetteandherald.co.uk/ The 16-page review outlines 20 recommendations to the agencies who encountered the family, including Social Services and Swindon and Marlborough NHS Trust. It says there were a number of missed opportunities for Social Services to intervene and assess the situation >> >> Aaron Gilbert,Swansea,May 2005,http://news.bbc.co.uk/1/hi/wales/south_west/6639447.stm A review has been carried out by the Local Safeguarding Children Board (LSCB) into the involvement of all local services leading up to the murder. It calls for a review of the department The report adds that, while many of the circumstances which led to Aaron's death could not have been predicted, lessons must be learned by everyone involved in the case. >> >> Danielle W Newcastle,2005 >> >> Aaron O'Neil 2005,Newcastle,http://news.bbc.co.uk/1/hi/england/tyne/4748450.stm Following Aaron's death, the Local Safeguarding Children Board (LSCB) commissioned independent expert Catherine Weightman to investigate the case. Her findings were published on Friday and found information sharing was insufficient to provide a full picture of the family history and risk to the child. Labour MP for Newcastle North Doug Henderson said he had written to the Health Secretary Patricia Hewitt calling for an external inquiry. He said: "I have asked the secretary of state to examine whether the agencies involved in Newcastle had applied the recommendations of the Laming Inquiry into the death of Victoria Climbie and the subsequent provisions of the 2004 Children's Act, and if not, why not?" At the same time Newcastle Primary Care Trust said it had carried out disciplinary proceedings against a female health visitor after concerns about her professional practices. This resulted in her dismissal. The member of staff is mounting an appeal. The review concluded that details were held by health and social services which identified O'Neil as a violent individual who presented a risk to women and children. Agencies were aware of the mother's history of childhood abuse and recent offending history. >> >> Alexanda Gallon,2005,Newcastle The Local Safeguarding Children's Board (LSCB) is to conduct a "serious case review" into the child's death. Independent expert Catherine Weightman will lead the review. She conducted a similar inquiry following the death of 92-day-old Aaron O'Neil, from Newcastle, who was killed by his father, Paul, last year. Chair of the Newcastle LSCB, "An independent expert was commissioned to take a thorough and impartial look at all of the agencies' actions, in line with the government's Serious Case Review arrangements. "Although there can never be a social worker, health worker, police officer or any other official in every person's home every hour of the day to look over children, where the report shows that there are lessons to be learnt by any agency, firm and decisive action will be taken." ``This case has been thoroughly investigated in line with government guidance by an independent expert who has concluded that Alexander’s death could not have been prevented. However, a number of lessons to be learned have been identified and all agencies with the Local Safeguarding Children’s Board will make sure that recommendations are acted upon.”