Death of a 15-month-old child in January 2015 as a result of multiple non-accidental injuries. Child S had been brought to live in the UK by his mother from the Czech Republic who abandoned him to the care of his adult half sister and her partner. He was not known to any services. The couple had a history of substance misuse and domestic violence. During the three months that he was in their care, he sustained significant injuries that led to his death. A number of friends and relatives were aware of the injuries to Child S but did not report it. The partner was sentenced to life imprisonment for murder and the child's half-sister was imprisoned for 5 years. Learning points identified include: the importance of using interpreters when working with families whose first language is not English; the need for information in a number of languages; the challenges of international migration for safeguarding children; the work needed to address the lack of knowledge or trust of professionals and services within migrant communities. Makes a number of recommendations related to working with migrant families.
      
 Title:  Serious case review: BSCB2015-16/04: born in 2013: died on 1st January 2015 aged 15 months. LSCB: Birmingham Safeguarding Children Board Author: Jim Stewart Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             1                              Independent Author:  Jim Stewart  Serious Case Review  BSCB2015-16/04 Born in 2013 Died on 1st January 2015  aged 15 months   2  Contents    Page 1. Reason for the Review 3 2. Methodology 3 3. Independent Lead Reviewer 5 4. Family Composition  5 5. Ethnicity, Culture and Identity 5 6. Family Background 5 7. Parental and extended Family Involvement 6 8. Criminal and Care Proceedings 6 9. The Local context 6 10. Summary of Key Events 7 11. Analysis 11  12. Conclusions and Lessons Learned    19  Appendices  Terms of Reference  Bibliography  Acronyms    22 24 25            3  1. Reason for the Review  1.1 Child S died on 1st January 2015 at 4.25 pm; aged 15 months old and had been living in England for approximately 6 months. An ambulance was called at 15.45pm to the flat where Child S lived latterly in the care of TL, TL’s partner MH and the couple’s 10-month old child SH. Child S arrived at hospital in cardiac arrest and could not be revived. Medical examinations and tests highlighted that Child S had experienced a number of injuries as a result of blunt force trauma.   1.2 A child protection medical for SH, was arranged on 1st January 2015 and this did not reveal any injuries. SH was placed in foster care and has been safeguarded through care proceedings.  1.3 Child S travelled to England with their mother in June/July 2014. Child S was abandoned and left in the care of AL and TL by their mother in September 2014 when she left England suddenly and returned to the Czech Republic where Child S had been born.  1.4 MH was found guilty of murder and sentenced to life imprisonment. TL was convicted of allowing the death of Child S and sentenced to 5 years’ imprisonment.   1.5 In February 2016 the Independent Chair of Birmingham Safeguarding Children Board requested that the Lead Reviewer undertake a Serious Case Review into Child S’s circumstances based on a desktop review of the information available from case records which West Midlands Police are able to provide from their investigation and the subsequent criminal proceedings.   2. Methodology  2.1 A Serious Child Care Incident Notification was made in respect of Child S on 1st April 2015.  2.2 Initial scoping undertaken identified which agencies had had involvement with Child S and the immediate family.  The following agencies provided background information about Child S’s circumstances:     Birmingham Community Health Care Foundation Trust  Birmingham Women’s Hospital Foundation Trust  Birmingham South Central Clinical Commissioning Group  Birmingham Early Years  Heart of England NHS Foundation Trust  2.3 West Midlands Police had no knowledge of the family before Child S’s death and West Midlands Ambulance Service and Birmingham Children’s Hospital only became aware of the family through the emergency call response and Emergency Department involvement on 1st April 2015. The family were not known to the Housing Department, National Probation Service, Sandwell and   4  West Birmingham NHS Foundation Trust or the United Kingdom Border Force.  2.4    The Independent Chair of Birmingham Safeguarding Children Board received reports on 29th January 2015 from the Serious Case Review Sub-Group and a further report presented on 20th May 2015 following further scoping and an updated recommendation from the Sub-Group.  2.5    The Independent Chair corresponded with the National Panel of Independent Experts on Serious Case Reviews about this case and an original decision on 24th June 2015 not to complete a Serious Case Review was given as there was nothing known at all about Child S, other than the details from the Police investigation and trial, that no agencies were aware of Child S’s existence. There is no record of Child S having come into the country.  Child S was not registered with universal services and there had been no concerns identified or referrals made to any agency. In addition, there is no evidence the other child living in the household had said anything.    2.6    The Independent Chair reviewed the decision upon the advice of the National Panel and on 2nd September 2015 agreed to ask the Lead Reviewer for another Birmingham case under review involving a migrant family of a different nationality but also from Eastern Europe to undertake a parallel review of Child S’s case at the same time.  2.7    This is an unusual Serious Case Review because Child S was not known to any agencies in Birmingham or apparently in England before their death. SH was registered with a GP and known to the Health Visiting Service. Child S was never registered with a GP and never seen by any health professionals. There were no home visits by any professionals to the family’s address during the period Child S lived there and there were no referrals to Children’s Social Care about Child S. It is understood that Child S travelled to England with their mother by aeroplane, but is not known to the United Kingdom Border Force. The information available to this review has come from the Police investigation of Child S’s death (including reference to Facebook posts between TL and other family members and friends), the criminal trial, and assessments by Children’s Social Care in respect of SH. The Lead Reviewer has also met MH in prison, who confirmed the information available from the Police investigation, Children’s Social Care assessments and other information gathered for the care proceedings in respect of Child S. This included some information provided to the Police and Children’s Services by authorities in the Czech Republic.  2.8    The Lead Reviewer has discussed the detail of a draft of this report with the Serious Case Review Sub-Group and made final revisions in the light of the feedback and further information received from members of the group.        5  3. Independent Lead Reviewer  3.1     Jim Stewart is an Independent Social Work Consultant with over 26 years’ experience of working in children’s services, child protection practice and management, including the coordination of complex case investigations and the conduct of Serious Case Reviews. He qualified as a Social Worker in 1986 and is registered with the Health and Care Professions Council.  4. Family Composition  Subject (Child S)                       Born 2013; died 1 January 2015 Mother (SL)                        Born 1977 Putative Father (MB)          Date of Birth Not known Half-sibling (AL)   Born 1997 Half-sibling (TL) Born 1995 TL’s partner (MH)                Born 1987 Niece of Child S (SH)                   Born 2014 Father of TL and AL (JL) Born 1976   5. Ethnicity, Culture and Identity  5.1    Child S, their mother SL, TL, AL, MH and JL were all born in the Czech Republic, a European Country which is a member of the European Union. MH is Roman Catholic, but does not practice his faith. MH comes from a gypsy background but the family had lived in houses for many years. MH also stated that JL is of Roma descent. There is limited information available about the cultural background of Child S and their family members.  6. Family Background  6.1 In interviews undertaken for Birmingham Children’s Services, relatives stated that SL had worked in Germany and that a previous partner had looked after her older children, TL and AL, in the Czech Republic for a period of their childhood.   6.2 MH told the Lead Reviewer that he and TL moved to England because JL lived here and they wanted a better life. MH had found some building work initially a few days a week.  6.3 Information received from the authorities in the Czech Republic following Child S’s death indicates that MH had been arrested for robbery with accomplices in 2004 and driving without a licence in 2007.  6.4 MH had used cannabis in the Czech Republic and told the Lead Reviewer that his parents had helped him to come off drugs without any involvement from health services there.   6.5    When AL moved to live with the couple, AL did not work but MH felt that she was good company for TL.    6  7. Parental and Extended Family Involvement in the Review  7.1     Agencies in Birmingham have had no contact with SL in relation to this Review. The Lead Reviewer met with MH as part of the review process but TL and her father JL chose not to be involved.   8. Criminal and Care Proceedings  8.1    MH was found guilty of Child S’s murder and sentenced on 22 October 2015 to life imprisonment. TL was convicted of allowing the death of Child S contrary to Section 5 of the Domestic Violence, Crime and Victims Act 2004 and was sentenced to 5 years’ imprisonment.   9. The Local Context  Birmingham   Census Information  9.1 The census in 2011 reported that:   1.073 million people lived in Birmingham. The city has a young population with 66% aged under 44 and 19% within the 20-29 years’ age group.   Birmingham is the ninth most deprived of the 354 local authorities in England.    Birmingham is the most ethnically diverse city in the United Kingdom.  9.2 An Overview of the Joint Strategic Needs Assessment for Birmingham 2012 organises information around the six Marston Review policy areas and the first is ‘Give Every Child the best start in life’. The subsection ‘Starting well: conception and childhood’ provides the following information:   Birmingham has high rates of perinatal and infant mortality. The infant mortality rate is 7.7 per 1,000 live births, compared to the England average of 4.7. Rates are significantly higher in ethnic minority groups.    10% of babies born in Birmingham weigh less than 2.5kg compared to 7.5% in England. Low birth weight is as high as 29% in some areas of the city.    Breast feeding initiation in Birmingham is low at 68.1% compared to 74.6% nationally.    Immunisation rates vary across the city. Rates of measles, mumps and rubella vaccination are lower in the south Birmingham area compared to the rest of the city.    7   9.3 The Joint Strategic Needs Assessment (JSNA) also highlights the following information about worklessness in the city:   The worklessness rate is 18.5% – higher than a year earlier (18.0%). It is higher compared to the West Midlands and England, 13.7% and 11.9% respectively.    Of the eight core cities, Birmingham’s worklessness rate is the second highest, and it is nearly two-thirds higher than the England rate. Worklessness is highest in the wards with the highest deprivation rate (IMD), such as Shard End (27.2%), Washwood Heath (26.9%), Nechells (26.3%), Sparkbrook (26.3%), Lozells and East Handsworth (26.0%), Soho (24.8%), and Aston (23.5%).   The Czech Republic  9.4 Child S was born in the Czech Republic. In 2010, the country introduced a National Action Plan for the Transformation and Unification of a System of Care for Children at Risk. In 2012 the Government approved a National Strategy to Protect Children’s Rights and an associated action plan.  9.5  It is not clear whether Czech child protection procedures bear much resemblance to those in England or if Child S had been subject to any legal order or child protection status when SL brought Child S to England in 2014. Children’s Services there had returned Child S to SL’s care after a period of time in an infant care facility due to her substance misuse and the need to assess her capacity for change.   10. Summary of Key Events   2002 Child S’s maternal grandfather, moved to live in England.  March 2012 TL and MH moved to England looking for work. MH clarified that they travelled by aeroplane. MH told the Lead Reviewer that they had been encouraged to move to England by JL.  The couple originally lived with JL in Solihull and eventually her father paid half of the money required for their own tenancy.  Within weeks of moving to England, TL found out that she was pregnant.   2013  May AL moved to England.  20 September Child S was born in the Czech Republic. SL is alleged to have been involved in prostitution and substance misuse for many years. MB is named on the Child S’s birth certificate but SL   8  subsequently stated that he was not the real father.  27 September TL and MH moved into the tenancy in Birmingham where they lived until Child S’s death.  20 October Child S was registered with a Paediatric GP in the Czech Republic.  21 October  SL denied substance misuse, but tested positive for methamphetamines and opiates. Child S was placed into an infant care facility in the Czech Republic.  5 November Czech town’s Children’s Services visited SL at home and assessed it to be clean and tidy.  6 November Czech town’s Children’s Services returned Child S to the care of their SL.    28 November Child S was reviewed by a Paediatric GP; Child S was due to be reviewed monthly and was seen in December 2013 and then February, March and April 2014.  2014  1 January   SL’s cooperation with Czech town’s Children’s Services reduced.  18 March SH, the child of TL and MH was born in Birmingham.  May AL moved to Birmingham.  26 May MB, Child S’s putative father reported to the authorities in the Czech Republic that SL had moved out of her address. She was wanted by the Czech authorities and was located living in a hotel in a nearby town. SL then failed to attend an appointment as agreed.  2 June MB attended the offices of a Czech town’s Children’s Services stating that he intended to apply for the custody of Child S.  June/July SL and Child S came to England.  MH recalled that SL had travelled in a taxi from London and expected them to settle a bill which cost approximately £150. MH recalls that the taxi driver called the Police before the fare was settled.  21 July MB informed the authorities in the Czech Republic that Child S and SL had moved to the United Kingdom.  June/July -  September  MH has told the Lead Reviewer that the presence of SL and Child S caused considerable friction in the flat. The Lead   9  Reviewer was told that SL allegedly took drugs in the flat and outside where she was involved in prostitution. SL regularly came back to the flat under the influence of drugs. SL argued with TL and did not listen to anyone. MH stated that SL made the house dirty and on occasion she would feed Child S with the same spoon she used for drugs. SL regularly promised to stop taking drugs but then continued to go out.   MH stated that they bought all the food and things for the flat. MH asked SL to leave every few days. MH went out a lot to avoid having to listen to SL. AL told SL to look after Child S. The situation at home led to a lot of arguments at home between TL, MH and other family members.   13 June SH was seen and weighed at baby clinic.  25 June SH received immunisations.  10 July The court findings at a Czech District Court confirmed that MB’s application for custody of Child S was not successful.  19 July An ambulance was called to the family’s address in Birmingham for a forty-year-old male, but no link between him and the family has been established.  23 July SH received immunisations.  August   TL and MH had rent arrears of £1,400.  From this point, rent was paid directly to the landlord.  JL, TL’s father, received a short custodial sentence for domestic abuse offences.  22 August SH was taken to the Health Visitor Clinic.  28 August SH was seen and weighed at clinic.  September SL left Child S in the care of AL, TL and MH. She told her children that she was going shopping and did not return. There was no discussion about her plans to return to the Czech Republic or any arrangements made for the care of Child S.  MH stated that he telephoned others about SL and his grandmother confirmed that SL had been seen back in the Czech Republic.   9 September Child S missed a scheduled appointment with a paediatric GP in the Czech Republic.  10 September SH received immunisations.   10   7 November SH was taken to the Health Visitor Clinic and weighed.  18 November In his summing up, the judge in the criminal trial of the couple highlighted that Child S was seen by a witness on this day with hair at the top of his head torn away; this had occurred within 10 days of TL and MH assuming sole care of Child S.  21 November TL sent a Facebook message to a friend stating ‘How is it here do you pay something. I can’t really go. I have to wait for the bruises to be gone or they will lock me up or they will think god knows…’.  At the end of November TL went to stay with JL with Child S and SH for a few days after JL had seen ‘damage’ to Child S during a visit to TL’s flat. When TL and the children returned home on the 26th November, it is stated that most of the marks had gone.  4 December  TL complained to JL through Facebook that she and MH were arguing.   7 December  TL complained to JL through Facebook that MH was complaining about ‘Child S’ and ‘he just beat me up’. (TL subsequently retracted the latter allegation).  15 December MH’s cousin and neighbour sent a Facebook post to JL father stating that MH was going to purchase a coffin for Child S, and TL should remove Child S otherwise he was going to kill him.  By 21 December Medical and other information considered at the criminal trial suggested that, by this date Child S had a fractured right big toe, other fractured bones, an avulsion (trauma/detachment) of the nail and significant loss of hair. TL made excuses to prevent JL from seeing Child S in this condition when he offered to care for the child for a period of time.  Late December A few days before Child S’s death TL responded to Child S crying out and saw MH holding Child S arm tightly causing marks and noticed marks around Child S’s mouth.  29 December TL sent a message to AL by social media stating ‘you (AL) have to take Child S home. I will pay Mom’s plane ticket on Wednesday so that she can come for Child S. I can’t do it no more I swear. Child S has bruises all on his face again.’   31 December TL and MH had a small New Year celebration in their flat attended by an aunt, her partner and their child.  2015  1 January   An ambulance was called at 3.45 pm to the flat, Child S was   11  transported to the Emergency Department where Child S arrived in a state of cardiac arrest. Cardio pulmonary resuscitation was continued but Child S could not be revived and died. Child S had bruising to the face, chest, back and limbs. A skeletal survey revealed fractures to the ribs, both arms and right big toe. Child S was also subsequently found to have had significant injuries to the diaphragm, lungs and liver and to be vitamin D deficient and malnourished. The Consultant Paediatrician reported that these were the worst injuries to a child they had seen in many years of practice in this field and health experts have confirmed that Child S will have experienced significant pain.  Child S died at 4.25 pm; aged 15 months old.  2 January Child S’s mother SL sent a Facebook message to TL stating ‘you what have you done to (Child S) you monster’.  11. Analysis   Child S’s life in England, legal status and care arrangements  11.1 Child S was brought to England from the Czech Republic by his mother and left in the care of the half-siblings. This was a private care arrangement precipitated by SL without the prior agreement of the AL, TL or MH and eventually the couple TL and MH were left to care for Child S on their own.   11.2 TL informed the Police during the criminal investigation that MH took on the care of Child S. He would not allow TL to bathe or dress Child S and on occasion would go to a different room to do this. This is contradicted by MH’s statement to the Lead Reviewer that they shared Child S’s care. A friend or relative described bathing Child S on occasion.   11.3 It has only been possible to form a limited picture of Child S’s life in Birmingham. There was not always food in the house (Child S was malnourished and vitamin D deficient when taken to hospital) and appears to have had no personal belongings. Child S lived in a house where substance misuse and domestic abuse impaired the care they received. Child S was the victim of regular and escalating physical abuse after AL returned to the Czech Republic and Child S experienced significant pain.   11.4 The United Nations Convention on the Rights of the Child contains the following definitions:    A separated child is ‘a child who has been separated from both parents, or from their previous legal or customary caregiver, but not necessarily from other relatives. This may therefore include a child accompanied by other adult family members’.    12   An unaccompanied child is ‘a child who has been separated from both parents or other relatives and is not being cared for by an adult who by law or custom, is responsible for doing so’.  Child S clearly became a separated child.  11.5 Ms Knaus, a Senior UNICEF Policy Adviser, reported to the House of Lords European Union Committee in 2016 that ‘we need inclusive child protection and integrated responses. We need a framework that works for all children so that trafficked children, unaccompanied children and children in families have their rights. We also know that children fall between categories. They move from one category to the next.’ Child S child arrived in England in the care of their mother but was left by her. Child S was then living with two half-siblings initially, but eventually with a half-sister who had had only a limited level of contact or relationship with Child S and her boyfriend, who was not a relative and neither had expressed any wish to care for Child S.   11.6 Agencies in Birmingham had no knowledge of Child S and were therefore unaware that Child S had been subject to welfare or child protection involvement in the Czech Republic.   11.7 MH told the Lead Reviewer that he and TL did not consider seeking help with Child S from authorities. The situation was very hard but MH emphasised that the couple’s loyalty to family influenced their decision not to seek help at any point.   Invisible or missing children: children not known to agencies in England  11.8 There are a number of child deaths documented where children had had no contact with professional agencies prior to their deaths. Their circumstances vary. For example, in 2010 Kristy Bamu (a 15-year-old boy from France) was accused of using witchcraft and killed after days of abuse whilst he and siblings were visiting his sister and her partner in London for a holiday.   11.9 There have been a small number of cases reported in this country of concealed pregnancies where mothers have not made agencies aware of their pregnancies or children’s births before the discovery of a deceased baby. A number of these cases have resulted in Serious Case Reviews. There are also isolated cases reported where slightly older babies have died and agencies had no knowledge of their existence until the discovery of a body. For example, the body of a boy aged between 12 and 18 months old was found near the A66 in Cumbria in 1989 and the body of a 6-month old girl was found on a path in Edinburgh in 2013 and Police have not been able to identify either child or their parents.   11.10 There is increased recognition that children can be brought into the country covertly by families or trafficked by criminal organisations but consequently there is little reliable evidence about the extent of such practice and the number of children involved. In 2001 there was significant coverage of the case of ‘Adam’, a young Nigerian child whose torso was recovered from the   13  Thames; in 2013 a woman came forward to claim that he was a child whom she had looked after for weeks in Germany before he was taken to London.  11.11 Although Child S was never known to agencies in this country, it has also been useful to briefly consider a number of well-known cases where agencies had lost touch with children and one high profile case where a child’s life history in other countries had not been known to professionals.    The case of Victoria Climbie and the Inquiry held following her death in February 2000 drew attention to the fact that a child had been brought into the country and their circumstances were not clearly understood by agencies and the limited efforts to contact agencies in France had been ineffective. However, a number of agencies and London councils had known Victoria. This case highlighted the practice of private fostering where children are cared for by someone other than a close relative.   Khyra Ishaq died in Birmingham in May 2008; she was described as extremely malnourished with severe wasting and her death was caused by bronchial pneumonia and septicaemia with meningitis. Kyra and some siblings had been removed from state education during December 2007 with a stated intention by her mother to educate them at home. The children educated at home were also effectively removed from health surveillance.   Hamzah Khan died in Bradford at the age of 4 years old in late 2009 as a result of fatal neglect but his death did not come to light until September 2011. The Serious Case Review commissioned by Bradford Safeguarding Children Board highlighted ‘the extent to which Hamzah was unknown and invisible to services throughout his short life.. …. Hamzah was invisible to services largely because neither of his parents participated in the routine processes such as ensuring he saw health professionals on a regular basis or was enrolled for early years to educational provision.’ In October 2009 Hamzah, his siblings and his mother had been removed from the register of the GP practice because the younger children had not been brought for routine health and developmental checks and immunisations. The legal requirement was that Hamzah should have attended school from September 2010.   Another case, the death of Dylan Seabridge at the age of 8 years old in 2011 in a remote rural community in Wales, is a slightly more recent example of how children can live ‘under the radar’ with no contact with agencies. Dylan died from a long term vitamin C deficiency (commonly known as scurvy) an easily treatable condition; he was found to have had anaemia and loose teeth. Media reports (for example in The Guardian) described Dylan as ‘invisible’ but his birth had been registered and his parents chose to educate him at home from 2006. Dylan was registered with a GP and a dentist but was not seen by either service and was not taken to a developmental assessment in 2006. In 2010, Pembrokeshire Council were alerted to the fact that Dylan and his   14  brother were being home educated but the boys’ parents denied professionals access to the children.  11.12 Child S came into the country with SL and apparently travelled with her from London to Birmingham. Child S did not come into contact with any childcare agencies in Birmingham at any time. Child S will have been known to a travel company and to the border agencies in the Czech Republic and England if Child S had travelled legitimately with SL from the Czech Republic; it has been suggested that they travelled by aeroplane.  11.13 The House of Lords European Union Committee has considered the situation of unaccompanied migrant children in the EU. It heard that at least 10 000 unaccompanied migrant children are missing in the European Union. The term ‘unaccompanied minor’ describes all foreign nationals below the age of 18 who either arrive in the EU unaccompanied by a responsible adult or who are left unaccompanied after their arrival.’  11.14 Child S’s presence in Birmingham was known to some people in the local community and to family and friends who saw, and some discussed, the injuries he suffered on Facebook. An obvious question for this Review to consider is why no adult alerted the authorities when concerns about the care of Child S emerged. TL was concerned that the authorities might intervene and remove her child if they were aware of the injuries to Child S and the care Child S was receiving. It is not clear how the other Czech people living in Birmingham who knew Child S viewed local agencies but they either did not think of informing the authorities or rejected such a course of action. (This is considered further on page 16).    The role of the Border Force  11.15 Border Force is a law enforcement command established in March 2012 and situated within the Home Office. It secures the UK border by carrying out immigration and customs controls at 140 sea and air ports across the UK and overseas to facilitate the legitimate movement of individuals and goods, whilst preventing those that would cause harm from entering the UK. This work clearly presents challenges. The service held no information about the arrival of SL or Child S into this country or SL’s departure without Child S.   Health care in the Czech Republic and in England  11.16 Child S’s circumstances in the Czech Republic and the move to England were not known to agencies in England prior to Child S’s death. Child S had been routinely monitored by a paediatric GP in the town Child S was born in and had missed an appointment thereafter Child S moved to England.  11.17 Child S was not registered with a GP and had no contact with any health agencies in Birmingham. Although SL talked on at least one occasion about taking Child S to Accident and Emergency, Child S was never taken to hospital.    15  11.18 MH did not register with a GP in England. He told the Lead Reviewer that health care appointments were free in the Czech Republic but, as in England, medication had to be purchased. He stated that he did not seek any medical advice or treatment for himself in England but did attend some ante-natal appointments with TL.   11.19 TL registered herself with a GP and SH had regular contact with a Health Visitor at the local clinic. SH was seen for a new born screening on 26 March 2014 and for a 6 to 8-week old assessment on 13 June. SH was seen seven times at clinic between June and November for routine assessment, developmental monitoring and immunisations. TL did not make health professionals aware that Child S had joined her household and contacts at clinic provided at least five opportunities to do so. It is not clear if the Health Visitor asked about any changes in the family’s circumstances. It appears unlikely that TL would have volunteered any information about Child S if she had been asked.   Working with fathers and male partners  11.20 MH told the Lead Reviewer that he had attended ante-natal appointments with TL. The Heart of England Foundation Trust have confirmed that MH had been used as an interpreter when TL was an inpatient on the Delivery Suite during the birth of her baby.   11.21 There was very limited contact with MH by health professionals but it is reasonable to expect that his presence at appointments or during home visits would have been routinely recorded and possibly that it could have been established if he was registered at a GP practice.   The treatment of Child S by TL and MH:  The meaning of the child  11.22 The circumstances in which Child S died are distressing and difficult to comprehend. It is striking how often TL and MH and others refer to Child S by gender only (not referring to Child S’s actual name) in their references online after mother had abandoned Child S in Birmingham.   For example, TL sent the following messages: ‘why are you writing to (X) and telling her that I’m beating up the child’.        ‘the child wakes up crying because he is hungry and (MH) shouts at them’.  11.22 The Lead Reviewer acknowledges that there may be a cultural dimension to the language used or an issue with translation but there were clearly issues around the relationships between TL and Child S and particularly MH and Child S.  11.23 In their books Beyond Blame (1995) and Lost Innocents (1999), Reder and Duncan highlighted and developed the concept of ‘the meaning of the child.’ They wrote: ‘some children in the household had been at greater risk of abuse than others because they acquired a particular psychological significance for their caretaker(s). It was as though the children acquired an undeclared script   16  or blueprint for their life that submerged their personal identity and characteristics and the meaning came to dominate the parent [carer]- child relationship.’  11.24 The meaning of the child includes ‘conscious and unconscious determinants of the parent’s [carer’s] attitudes to, feelings about and relationships with the particular child’. Note: the Lead Reviewer has added the text in brackets within these quotes.  11.25 Reder and Duncan went on to consider the meaning of a child to fathers and the Lead Reviewer suggests that this can be extended to male carers. They note ‘that ‘the child may be experienced as a ‘stranger’ competing with him for the mother’s [in this case it would be female carer’s] attention and giving him nothing emotionally in return.’  11.26 SL’s view of Child S is not known. She had not been the primary caregiver for TL or AL for periods of their childhood. She came to Birmingham and allegedly abdicated responsibility for Child S’s care and then abandoned Child S with TL and AL.  11.27 TL and MH were left to care for Child S when AL returned to the Czech Republic. There is little evidence of any positive relationship between either TL or MH with Child S. SL had come to their home without invitation and they then struggled with the additional responsibility of caring for Child S.   11.28 Police investigating Child S’s murder reported that there were no pictures of Child S in the home and no appropriate children’s clothing for them.   The Relevance of Religious Beliefs  11.29 There has been increasing awareness of child abuse linked to faith and belief in this country over the last twenty years. This is reflected in national guidance; Safeguarding Children from Abuse linked to a Belief in Spirit possession (DfES 2009) and the National Action Plan to tackle child abuse linked to faith or belief (DfE 2012). It follows a number of cases where parents, carers or relatives have sought to justify ill-treatment because of a belief in witchcraft or spirits. In the case of Child S, TL and MH apparently tried to blame ghosts or spirits for causing injuries and bruising.   11.30 Media reporting of the trial of MH and TL highlighted the references the couple made to ‘duch’ (a Czech word for ghost or spirit) in communication with others about the injuries to Child S. MH had allegedly talked about a neighbour saying that a woman and child had died in a fire in the flat in the 1980s. The couple also reportedly spoke about TL’s recently deceased grandmother. TL reportedly told people that there were ‘ghosts and spirits in the bedroom’ and that Child S was targeted because the child slept in a bed on their own.   11.31 The Lead Reviewer has not been able to discuss this issue with TL but MH has indicated that TL did not believe that this was the real cause of Child S’s injuries. The Police heard in the course of their enquiries that JL and other   17  people had told her that MH was responsible for the injuries to Child S and that she was naive for believing that such injuries had been caused by spirits or ghosts.   Knowledge of the treatment of Child S within TL’s and MH’s wider family and social networks  11.32 A small number of family, friends and relatives observed bruising and injuries to Child S during visits to the family’s flat in November and December. TL and MH had told them that some of them were caused accidentally and as described above talked about spirits on other occasions. One friend had bathed Child S once in November and once in December and informed the Police that they did not observe any bruising on those occasions. TL also communicated with family and friends using private messages on Facebook.   11.33 She had a number of Facebook ‘friends’ including family members and friends amongst the Slovakian community in Birmingham. On 21st November 2014, maternal grandfather, asked TL what had happened to the child because he had seen photographic evidence of bruising on Child S’s face. He also agreed to TL and the children spending some time with him after visiting the flat. Also in November 2014, TL asked her sister AL (who was back in Slovakia) why she was telling people ‘I’m beating up the child’. Maternal grandmother also sent a message to TL asking ‘why are you beating the child up like that’.  11.34 It is not clear why the adults who were aware of the injuries to Child S did not report the matter to either the Police or Children’s Social Care or to Health professionals whom they had contact with.  11.35 Birmingham Safeguarding Children Board considered the issues of community trust in public services and community engagement raised in the Serious Case Review completed in 2010 following the death of Kyra Ishaq. The review noted the great diversity of the population within the community where Kyra’s family lived and also reports that many residents, particularly those who have arrived recently from other countries, (were) fearful and mistrusting of engagement with authority figures at any level. The Review recommended that ‘The Children’s Trust in conjunction with the Birmingham Safeguarding Children Board should initiate an education campaign with supporting literature, to build public trust and confidence in ways to effectively safeguard and protect other people’s children’. It also suggested engagement at a community level and particularly with the younger members of the various communities. The review’s author highlighted the potential role of nurseries, crèches, playgroups, community health and schools and proposed that the production of key community safeguarding messages in a range of languages for adult audiences, which young people could reinforce, may be beneficial. Birmingham Children’s Trust and Safeguarding Children’s Board oversaw a public awareness campaign in 2011 in response to these recommendations. A campaign evaluation report was to be shared with the Children’s Trust and Birmingham Safeguarding Children Board but no information has been provided to this Review; this calls into question the progress made.     18  Housing and Finances  11.36 MH described the accommodation that he and TL lived in as poor. He had had an argument with his landlord about a failure to make improvements and rent arrears during a home visit from the Midwife who was visiting his child.   11.37 MH told the Lead Reviewer that a friend had helped him to navigate the benefits system. MH had received Housing Benefit, Jobseeker’s Allowance, Child Benefit and Tax Credits.  11.38 On 1 January 2015, there was very limited food in the flat and the fridge freezer was broken.  Language and communication  11.39 The Heart of England NHS Foundation Trust have reported that records do not state whether an interpreter was used at the initial booking appointment. An interpreter was booked for the 2nd antenatal clinic appointment; however, TL did not attend this appointment. The interpreter was used instead to relay information to her by telephone from the clinic and inform TL of her next appointment. There are no further entries which suggest an interpreter was used again.   11.40 Staff had used MH as an interpreter when TL was an inpatient during the birth of their child. There is a current discussion at the hospital re using partners to interpret at this point given that this is a personal time and there is a view that it is not appropriate for strangers in the room or to use telephone interpreting at this time.  11.41 MH told the Lead Reviewer that there were no offers of interpreters by health professionals and no information offered in their first language. He spoke a little English when they first moved to England and his English has steadily improved; TL could not speak any English when they first moved.   11.42 There has been no indication by the Health Trusts involved with SH that TL and MH received any written information about local services in their first language.   Communication between agencies in different countries   11.43 The issue of communication between Children’s Services in England and their equivalent services in other countries was considered by the Victoria Climbie Inquiry.  It was only following Victoria’s death that it was established that ‘she was known to French Social Services and Victoria’s school in Paris had registered a Child at Risk Emergency Notification with the French education authorities on 9 February 1999, because of Victoria’s repeated absences from school’.  The Climbie Inquiry recommended that Directors of Social Services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries.   19   11.44 There is a well-established procedure and alert system in England to implement when a child or children subject to child protection enquiries or a child protection plan goes missing from a Local Authority. Custodians of lists of children subject to a child protection plan and lead health professionals are informed when these children go missing. There is also newer guidance, Working with Foreign Authorities (Department for Education July 2014), in respect of communication with other countries when social workers are working on child protection cases or with children subject to care proceedings or orders. Communication with Embassies is recommended when children are made subject to care proceedings or child protection plans and also liaison through the International Child Abduction and Contact Unit (ICACU) when a child moves to another country or a placement abroad is being considered or proposed.   11.46  Birmingham Council and its partners did not receive any communication or information about Child S from the Czech Republic. This Review has provided an opportunity to consider what additional specific procedure or guidance may have been available to workers if any request for information or intervention had been made. The Association of Directors of Children’s Services has highlighted Lincolnshire Local Safeguarding Children’s Board procedure on Cross Border Child Protection Cases under the Hague Convention as an example of good practice because it also includes a section on handling requests for assistance from other contacting States when they are made. Birmingham Safeguarding Children Board procedures currently include a section of practice guidance about Children and Families moving across Local Authority borders. Birmingham Children’s Services internal procedures include a link to the Department for Education (DfE) 2014 Working with Foreign Authorities guidance but not to the DfE 2012 guidance about Cross-border child protection cases: the1996 Hague Convention.  12. Conclusions and Lessons Learned  12.1 Child S suffered extensive and fatal physical abuse and neglect when he was abandoned by his mother and left alone in the sole care of TL and MH. These adults had had involvement in Child S’s care for three months by this time, but had not agreed to be the child’s carers. MH has described considerable tension between the adults in the home following mother’s and Child S’s move to Birmingham. Health professionals had no concerns about TL and MH’s care of their own child but, with hindsight, it is clear that there was domestic abuse and paternal substance misuse which is likely to have compromised the parenting of both children. The couple lived in poor housing and had very limited finances.   12.2 As the House of Lords 2016 report states, all children needing protection have the legal right to receive it regardless of immigration status, citizenship or background. Dorling’s report for the Coram Children’s Legal Centre in 2013 about the rights of undocumented migrant children in the UK noted that ‘Many undocumented children are brought into the UK by a parent or guardian…. Some come to the UK, lawfully when they are very young…. In some cases,   20  family relationships may break down, leaving children abandoned and left to be taken into the care system’. Agencies in Birmingham were not afforded the opportunity to safeguard or promote the welfare of Child S as they were never aware that he was living in the city. There was no professional involvement with Child S for this Review to consider.  12.3 This case highlights the considerable challenge to child care agencies presented by international migration particularly when parents and carers, extended family members and members of the community do not understand how to, or choose not to, engage with professionals. The mobility of children and families between countries in Europe has been the subject of considerable national discussion as has the increased international migration of people around the world as a consequence of global events in the last few years.   12.4 Child S had spent time following birth living away from SL in state care in the Czech Republic whilst she was expected to address her substance misuse. This Review has not received any information about the quality of the assessments undertaken in respect of Child S and SL . Child S was also the subject of private law proceedings in the Czech Republic and the application for custody by a putative father was rejected. It is clear that agencies in the Czech Republic had expected SL  to cooperate with them and to make herself and Child S available for appointments. There has been no information presented to this Review to suggest that Child S was subject to any formal child protection planning process or legal status when taken out of the country by SL. If the Czech authorities had shared the reports that Child S had moved to England and their concerns about Child S’s care with agencies in England, there is no guarantee that professionals in Birmingham would have been able to establish contact with Child S; however, a request could have been made for the Police to make enquiries with the half-sisters if information had been provided about them.  12.5 Routine health services were provided to TL and her child. This case serves as a reminder that family and home circumstances change and that it is important for professionals to periodically ask about any changes. It also highlights the mistrust of professionals by some parents and carers and members of the community and the fact that some families will actively avoid information sharing or contact with professionals who wish to support families and safeguard children.  12.6 Agencies in Birmingham have been attempting to build links with the diverse range of communities in the city to promote safe parenting and child protection for a number of years. The Lead Reviewer recognises the difficulty of evaluating any campaign by a Safeguarding Children Board to convey safeguarding messages to, and to influence the behaviour of, members of the community and also that due to the changes in our communities that any such exercise would need to be repeated periodically.       21  Learning Points  12.7 This Review has highlighted a number of learning points for the Birmingham Safeguarding Children Board to consider further and to highlight through internal agency and LSCB multi-agency safeguarding training:  1. The absence of any reference in local procedures or the current version of the Working with Foreign Authorities guidance to circumstances when child protection enquires have been recently undertaken or are ongoing in respect of children moving countries or recognition. Any future revision of the guidance could usefully acknowledge that good communication and joint working are important in these situations as well as when implementing child protection plans.  2. The importance of using interpreters when working with parents, carers and children whose first language is not English to ensure understanding and informed consent.  3. The need to provide information in a number of languages and to consider translation when introducing leaflets particularly for new arrivals to the country.  4. The complexities and challenges of international migration for work with families and safeguarding children.  5. The work still required to address the lack of knowledge or trust of professionals and services within migrant families and communities.  6. The importance of professional curiosity and potential value of periodically enquiring about any changes in a child or family’s circumstances.  7. The need to identify fathers and include information about them in assessments and records.   8. The key roles of the Home Office, Immigration and Visa Service and Border Force and the contribution they can make to assessments of migrant and asylum seeking children and families.   9. The importance of community engagement and the potential for future LSCB campaigns and evaluation reports to encourage discussion and understanding about the early help offer in the city and child protection referral processes and the tragic case of Child S.   Birmingham Safeguarding Children Board will consider the actions necessary to take forward the learning from this Review.  Jim Stewart Lead Reviewer 28 February 2017   22  Appendices  Terms of Reference                      BIRMINGHAM SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE  SERIOUS CASE REVIEW Date of birth: 2013   Date of death 01.01.2015  The Chair of Birmingham Safeguarding Children Board confirmed to the Lead Reviewer on 23 February 2016 that the terms of reference are to:  1.  Review everything that is known from the case records about Child S until the point of Child S’s death  2.  Review everything that West Midlands Police are prepared to release pertinent to the investigation and subsequent legal processes that may add learning in relation to Child S.  3.  Address the following questions:  a. Why was Child S never recorded as entering the country, if it can be established  b.  Identify what, if anything, is required of migrants from Eastern Europe entering the UK in relation to their children  c.  Establish whether there is any advice provided to migrants in relation to their children in terms of registration with the NHS through a GP and school attendance requirements, nationally or by any agency in the city  d.  If provision exists, how migrants are identified to initiate this provision.  e.  Establish whether the criminal investigation identified whether there were any referrals, queries or concerns made by neighbours, those using social media, or professionals about Child S.  f.  Establish whether there is anything to be learnt about the actions or absence of actions by public sector services in relation to Child S.  g.  Establish from police records whether any learning in relation to Child S about how agencies worked together to safeguard children.  h.  Identify potential ways to apply that learning for the Council, the Birmingham CCG’s, West Midlands Police, Border Force, housing providers, other Government Agencies and National Government  i.  Prepare a report for publication on Child S, which forms part of a larger publication in relation to Child S and another case.   23   j.  Utilise any themes arising from Child S as part of a wider short thematic review of the needs of migrant eastern European children coming to live in Birmingham   24  B.  Bibliography   Birmingham Council/ BDP Service Development Team, Planning and Regeneration - International Migration in Birmingham 2012-13 (2015/01)  Birmingham Health and Wellbeing Board - An overview of the Joint Strategic Needs Assessment for Birmingham (2012)   Coram Children’s Legal Centre/ Dorling K - Growing up in a Hostile Environment: The rights of undocumented migrant children in the UK (November 2013)  Department for Education - Cross-border child protection cases: the1996 Hague Convention Departmental advice for local authorities, social workers, service managers and children’s services lawyers (October 2012)  Department for Education - Working with foreign authorities: child protection cases and care orders Departmental advice for local authorities, social workers, service managers and children’s services lawyers (July 2014)  EU Migration to and from the United Kingdom – The Migration Observatory/University of Oxford (October 2015)  House of Lords European Union Committee - Children in crisis: unaccompanied migrant children in the EU HL Paper 34 (July 2016)  National Institute for Health and Care Excellence – Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. NICE Clinical guideline CG110 (September 2010)  Ofsted - Ages of concerns: learning from Serious case reviews (October 2011)  Reder P, Duncan S and Gray M - Beyond Blame Child Abuse Tragedies revisited (1993)  Reder P and Duncan - S Lost Innocents A follow-up study of fatal child abuse (1999)  Research in Practice – Confident practice with cultural diversity: Frontline Briefing (July 2015)   University of East Anglia/NSPCC/ Brandon M, Bailey S, Belderson P and Larsson B Neglect and Serious Case Reviews (January 2013)  Websites  Ministry of Labour and Social Affairs of the Czech Republic International Child Abduction and Contact Unit       25   C. Acronyms   BSCB: Birmingham Safeguarding Children Board   DfE: Department for Education  DfES: Department for Education and Skills   ICACU: International Child Abduction and Contact Unit (ICACU)  JSNA: Joint Strategic Needs Assessment   LSCB: Local Safeguarding Children Board   