Executive summary of a review into the death of a 4-year-old girl in 2011, from multiple stab wounds. Suicide notes indicated that Child D was killed by her mother who then attempted to kill herself. Mother had recently been dismissed from her job and was due to attend court in relation to offences in contravention of the Data Protection Act. Following her dismissal, mother maintained the pretence that she was employed to family, friends and Child D's nursery. Identifies additional stress factors that likely contributed to mother's actions, including her failure to gain employment because of unsatisfactory references and the breakup of her relationship. Issues identified include: lack of agency knowledge of father or mother's partner's role in Child D's life; and history of violence and convictions of adults related to the case. Makes recommendations for police, probation, health, children's and childcare services including improved provision of child protection training to child minders and nursery staff.
      
 Title:  Serious case review: Child D (Case Arlene 11): executive summary LSCB: Bury Safeguarding Children Board Author: Dennis Charlton Date of publication: 2012  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   Bury Safeguarding Children Board  Serious Case Review  Child D (Case Arlene 11)   SERIOUS CASE REVIEW  EXECUTIVE SUMMARY  Report Author:  Dennis Charlton Date:    12 September 2011    Signed:   Date:  12/09/11    Commissioned by: Bury Safeguarding Children Board  2 I can confirm that the Serious Case Review on Child D (Case Arlene 11) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Monday 12 September 2011.  BSCB members agreed to accept the health overview report, Serious Case Review Overview Report, Serious Case Review Executive Summary and multi-agency action plan for submission.  I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Executive Group will monitor their implementation.  The Overview Report and Executive Summary, suitably redacted and anonymised, will be published on the BSCB website at the conclusion of the Ofsted evaluation and any criminal and coronial enquiries.                      Gill Rigg       Independent Chair of BSCB   On 10 June 2010, the Parliamentary Under Secretary of State for Children and Families, Tim Loughton, Member of Parliament wrote to Local Safeguarding Children Board (LSCB) Chairs and to Directors of Children’s Services, and advised them of a change to the Working Together guidance. He advised that LSCBs should publish all Serious Case Review (SCR) overview reports on cases initiated after 10 June 2010, suitably anonymised and redacted. This is in addition to the publication of the executive summary.  This overview report is published in accordance with that direction and has been redacted and anonymised by Bury Safeguarding Children Board.  The sentences which have been redacted or amended are shown in blue.  Signed: Date: 12 September 2011  3  Introduction  1.1  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. A 4 year old girl, Child D, was found dead in bed at the family home. From suicide notes it appeared that the child’s mother, Adult MD had killed her daughter and intended to take her own life.   1.2 A post mortem confirmed that Child D died from multiple stab wounds. The mother had ingested a bleach-based solution, apparently in an attempt to kill herself. At the conclusion of the Serious Case Review, the mother remains in hospital, in a serious medical condition. Because of health issues, the Police were unable to interview mother until very recently.  At the completion of this Serious Case Review, Police enquiries were still ongoing.  1.3 Bury Serious Case Review Panel met on 16 March 2011. The initial recommendation from the Serious Case Review Panel was that the case did not meet the criteria for a Serious Case Review.  1.4 The Chair of Bury Safeguarding Children Board made a decision on 18 March 2011 that the criteria for undertaking a Serious Case Review were met.  1.5 Ofsted were informed on 18 March 2011 that a Serious Case Review was to be undertaken.  2. Terms of reference and the SCR process  2.1 The following key lines of enquiry were agreed for the Serious Case Review:  • Did each agency have in place policies and procedures to safeguard the welfare of children and vulnerable adults to whom they had responsibilities;  • Did agencies have the opportunity to work together and communicate effectively to promote the welfare of Child D;  • To what extent were relevant intra and inter agency policies and procedures followed in this case and were there any barriers to effective working practices;  • Were practitioners knowledgeable about the indicators of abuse and neglect including the impact of domestic abuse and how did this inform agency responses to any issues of concern;  • Establish to what extent there was an opportunity to consider the impact of mother’s ex-partner upon the functioning of the  4 family and whether the issue was given appropriate emphasis within agency assessments and interventions;  • To what extent did services have an understanding of Child D, her experiences and views, and how did this inform the service;  • To what extent did services take account of diversity issues such as race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery;  • Was the management oversight and supervision in the case adequate;  • In relation to any similar themes arising from this case, are these issues from previous SCRs, which agencies have previously acted upon.  2.2  In addition to the Individual management Reports (IMRs), the Overview Report author attended a number of Serious Case Review Panel meetings, as an observer, in order to clarify any issues in relation to the IMRs.  2.3 The following agencies contributed to the Serious Case Review process:  Agency Contribution Greater Manchester Police Submitted Individual Management Report Bury Council Children’s Services Social Care Submitted Individual Management Review Bury Council Childcare and Extended Services Submitted Individual Management Review Bury Council Children’s Services Learning Division, (School & Nursery) Submitted Individual Management Review Pennine Care Foundation NHS Trust (Community Services, Bury)- including Health Visiting and GP services Submitted Individual Management Review Pennine Acute Hospitals NHS Trust Submitted Individual Management Review Greater Manchester Probation Trust Submitted Individual Management Review     Information was also requested from: Pennine Care Foundation NHS Trust (Adult Services)  A Health Overview Report was also commissioned.  5 The Serious Case Review Panel was:-   Colleen Murphy Chair of The Serious Case Review Panel   Detective Inspector, Child Death Review Team, Greater Manchester Police   Service Manager – Safeguarding Unit, Bury Council Children’s Services Social Care   Designated Nurse for Safeguarding, NHS Bury  Head of Service, Bury Child Care and Extended Services, Bury Council  Child Safeguarding Lead, Pennine Care Foundation NHS Trust  Lead Officer-Safeguarding, Learning Division, Children’s Services, Bury Council   Consultant Paediatrician, Pennine Acute Hospitals NHS Trust   Assistant Chief Executive, Greater Manchester Probation Trust   The Overview Author attended a number of SCR Panel meetings as an observer.  The Overview author also had a conversation with the Information Commission in order to clarify some issues.  The Independent Chair of Bury Safeguarding Children Board is Gill Rigg.  3 Independence within the SCR Process  3.1 The Chair of the SCR Panel was Colleen Murphy. Ms Murphy is an Independent Consultant Social Worker. She has considerable experience of child protection and child welfare and had contributed to a number of SCRs both as a Chair of SCR Panels and also as an Overview author.  3.2 The Overview Report author was Dennis Charlton. Mr Charlton is a former Assistant Director of a local authority Children’s Service and is now an Independent Consultant in Child Protection. He has considerable experience of child protection and child welfare and had contributed to a number of SCRs both as a Chair of SCR Panels and also as an Overview author.  6 3.3 All of the Individual Management Reports were undertaken by managers who had no direct involvement with the case.  4.  Parallel Processes  4.1 A criminal investigation remains in progress at the conclusion of this SCR. The Police Investigation had not been completed, largely because mother’s medical condition, following her suicide attempt, meant that Police interviews with mother had only just commenced and further Police enquiries were required. Ongoing discussions will continue, as necessary, between the Crown Prosecution Service, the Police and the SCR Panel.  A Coroners Inquiry has not as yet concluded. Bury Safeguarding Children Board will ensure that the Coroner and the Child Death Overview Panel are updated about the SCR process.   5.  Involvement of the Family  5.1  The father (FD) of Child D was informed about the Serious Case Review and invited to contribute to the process. The former partner of MD (XP) was also contacted and asked if he wished to make a contribution to the SCR. The maternal grandparents of Child D were contacted and asked if they wished to contribute. None of the individuals contacted indicated that they wish to make a contribution although they will be contacted again to seek any contribution they may wish to make.  The mother (MD) has also been informed about the Serious Case Review but her contribution will depend upon her physical recovery and also be influenced by any criminal investigation or proceedings.   6.  Case Summary  6.1  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. In 2006 Child D was born following a caesarian delivery. Mother and baby were discharged from hospital four days later.  Initially the household comprised of Mother (MD), Father (FD) and Child D.  6.2  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.  Routine community midwife home visits recorded that Child D was developing well and was of a good weight.  6.3  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.  In June 2007 a domestic incident was reported to the Police. MD took Child D and herself to maternal Grandmother’s home.   7 6.4  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. A joint visit was made by a Social Worker and Police Officer in June 2007.  MD was seen at the home of maternal Grand Mother. Further support, which MD declined, was offered from both Children’s Social Care and the Police. NHS Bury, Safeguarding Team, were also advised by letter about the incident and action taken.  6.5  Following this incident MD and her partner separated. MD and Child D continued to live at the family home.  6.6  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.  In October 2007, MD reported an incident where FD arrived at the family home for contact with Child D and was perceived to be under the influence of alcohol. MD refused to allow contact to take place and this led to an argument, with some threats from FD. MD reported this incident to the Police. Children’s Social Care was informed of this incident by the Police four days later. A letter was sent from Children’s Social Care offering support should MD wish for it. The incident was also reported to NHS Bury Safeguarding Unit by Children’s Social Care.  6.7  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. From the available information, contact between FD and Child D ceased when mother started a relationship with XP.   6.8  In April 2008 Child D also started being in the care of a registered child minder, initially for two days per week.   6.9  This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable.   6.10  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. MD and XP started a relationship in July 2009.   6.11  This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable.    6.12  This paragraph has been redacted as it contains sensitive personal information, which may potentially be identifiable.   6.13 Mother, who is a trained and qualified health professional, changed her employment in September 2009. Her new role gave her access to information about patients who had suffered injuries because of accidents.  6.14  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be  8 identifiable. Mother had known XP since childhood. Police information suggests that she was aware of XP’s background. XP moved into the family home in December 2009. XP had at this stage started working as a salesman for a firm specialising in claims for personal injuries.  6.15  Mother and XP reached an agreement that she would use her role as a health professional, to supply him with detailed information about patients who had suffered injuries because of accidents. This information would enable XP to solicit their custom and increase his commission for attracting new customers.  6.16  In February 2010 a complaint was made to the NHS Trust, responsible for the service where mother was employed, that personal data had been given out in contravention of the Data Protection Act. An investigation by the NHS Trust took place.   6.17  Investigations led to MD being identified as the person who had seemingly inappropriately accessed patient files on numerous occasions. MD was presented with this information at a formal meeting and suspended by the agency employing her in May 2010.  6.18  Ongoing investigations led to a disciplinary hearing and MD was dismissed by her employer, in August 2010.   6.19  MD had not informed either family or friends that she had been dismissed from her post and there is evidence from the Police IMR that she continued to dress in her NHS uniform on a daily basis, in a pretence that she was still working. Mother also continued to use her child minder for Child D.  6.20  Child D started attending the nursery attached to the local Primary School in September 2010.  6.21  In January 2011 XP finished his relationship with MD and left the family home. Evidence from the Police IMR suggests that he repeatedly declined MD’s requests to continue their relationship.  6.22  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.  In February 2011 MD failed in her attempt to gain employment because references were unsatisfactory (they revealed her dismissal for breaching confidential patient information).  6.23  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.  On the same day MD had taken Child D to the child minders and was picked up by MD, as usual, in the afternoon. The child minder then received two text messages from MD to say that she (MD) intended to take Child D to nursery the following day. A further text message from MD said that Child D was unwell and that MD intended to keep her off school.  9  6.24  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable.   During those two days mother sent a number of text messages to XP blaming him for her present problems. MD also sent a further text to the child minder saying that Child D was still ill.  6.25  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. Two days later Maternal Grandmother (MG), who had been increasingly worried about being unable to contact MD, visited the family home and asked a neighbour to force an entry. Child D was discovered dead in an upstairs bedroom with MD beside her. MD was believed to have ingested a toxic substance.  7.  Key Issues and Lessons from the Serious Case Review  7.1  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. Although not directly related to the death of Child D there were themes identified in this case of domestic violence and  alcohol misuse.   7.2  All of the key agencies involved in the case have comprehensive domestic violence policies and procedures that are actively monitored. The interventions, in response to domestic violence incidents, particularly from the Police and Children’s Social Care were appropriate and timely. There was evidence of a very good working relationship between the Police, Children’s Social Care and Community Health Services in relation to domestic violence.  7.3   Even though there was evidence of effective joint working in cases of domestic violence, this Serious Case Review has identified a need for a more strategic approach to domestic violence that involves information sharing with General Practitioners and a more proactive role for Community Health practitioners. A specific recommendation is made in the Overview Report that addresses this.  7.4  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There were some issues about information sharing between agencies and there were a number of occasions when the Probation Service should have shared information with Children’s Social Care. The Probation Individual Management Review addresses these issues in some detail and makes appropriate recommendations for future involvement of the service with domestic violence cases.  7.5  There were weaknesses identified, across all agencies, in how information about race, religion, language, and other forms of diversity were collected and recorded. Although this did not have a  10 negative impact on this particular case, a recommendation is made to address this.  7.6  There was also a failure within the nursery to internally report a low level concern. Whilst this was unlikely to alert agencies to any concerns, it does indicate a need to be vigilant about even small pieces of information.  7.7  There were some issues identified about the importance of supervision for professionals and in particular the need for reflective supervision. This Serious Case Review identifies the need for findings from this SCR to be woven into any new guidance in relation to the recently published Munro Review.  7.8  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There is evidence of a tendency of some agencies to limit their thinking to immediate problems and not focus on wider issues. This is relevant for example when an adult related to the case attended the hospital Accident and Emergency Department on one occasion. Although the adult gave a history of extensive alcohol and some drug misuse, there was no attempt to seek information as to whether the adult had any caring responsibilities. This “silo” mentality has been described in research on child protection and is a feature of some elements of this case.  7.9  A further key issue lies with the potential for agencies identifying that MD had reached such a level of desperation. There had been a number of significant and extremely negative events that had occurred to mother in a relatively short space of time. She had been suspended and dismissed from her employment because of a misuse of patient information. The relationship between her and XP had terminated and there are suggestions that this caused her considerable distress. She had recently failed to be employed because references (following her dismissal) were unsatisfactory.  7.10  These events took place in a context where MD was still pretending to friends and family that she was in employment.  7.11  It seems a reasonable hypothesis, in this case, that MD felt overwhelmed by the cumulative impact of these events and the very tragic outcome may well have been an altruistic attempt to “save” Child D from the cruelties of the world. Certainly this would be consistent with the available research on maternal filicide.   7.12  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. There was, in fact, very little agency involvement with the family leading up to Child D’s death. The only agencies with any real involvement were the childminder and the nursery. The NHS Trust were only involved because of the disciplinary issues and the misuse of patient information.  11 7.13  There were also no reported concerns about Child D and no incidents that would have raised agency concerns about the potential for harm to Child D. There have, however, been a number of cases on a national basis of both maternal and paternal filicide linked to the adult carer attempting suicide and all agencies working with children and families need to be aware of the research findings on this issue. A specific recommendation is made in the Overview Report covering this.   7.14  In these circumstances the very tragic death of Child D was neither predictable nor preventable. There are however some lessons that can be learned from this SCR and these are reflected in the Individual Management Review recommendations and the Overview Report recommendations.   7.15  One particular area of concern is that there were clearly some significant differences between some agencies about whether the threshold had been met, in this case, for a Serious Case Review. This suggests that there is a need for Bury Safeguarding Children Board to clarify both the thresholds and also the process for undertaking Serious Case Reviews.   8. Recommendations   Overview Report Recommendations  All of the recommendations (both Overview Report and Individual Agency recommendations) will be actively monitored by Bury Safeguarding Children Board in line with the Action Plan.  1. Bury Safeguarding Children Board should ensure that the findings from this Serious Case Review are made available to practitioners and that the issue of filicide is given prominence in training and awareness programmes for staff.  2.  Bury Safeguarding Children Board should take the strategic lead in setting standards for information that is recorded on race, ethnicity, religion, disability and other forms of diversity. There should be a regular audit of this information and the findings reported to BSCB.  3. Bury Safeguarding Children Board should review their processes for determining when Serious Case Reviews should be undertaken and in particular ensure that there is a shared understanding of the criteria for undertaking Serious Case Reviews.   4. Bury Safeguarding Children Board should request Pennine Acute Hospitals NHS Trust to introduce audit and monitoring systems to ensure that documentation about adult patient “caring responsibilities” is properly considered and recorded.   12 5. Bury Safeguarding Children Board should, in considering any implementation of new guidance on supervision, ensure that the findings from this SCR are woven into that new guidance.  6. Bury Safeguarding Children Board should take a strategic lead in a multi agency review of domestic violence working arrangements.  Individual Agency Recommendations  POLICE  1. That the Operational Communications Branch Commander issues a reminder to operational control room staff, via branch orders, of the critical reasons for the correct application of Force Wide Incident Number (FWIN) closure codes when finalising incidents of domestic violence and abuse.  CHILDREN’S SOCIAL CARE  1. Ensure that referrals are dated at the time of contact, rather than at the time they are confirmed in writing.  2. Continue to ensure that Initial Assessments are undertaken if a visit is made or if parents are invited into the office.  3. Explore whether and how schools may be informed of Domestic Abuse notifications where the decision has been made not to undertake an Initial Assessment.  4. A copy of agreed action for all cases screened with the Police is retained by Social Care, not just those where action has been agreed.  5. Review practice of sending letters to parents when no further action is agreed.  6. Provide improved guidance to assist judgment about the severity of incidents and ensure practice adherence.   GREATER MANCHESTER PROBATION TRUST  1. The service should ensure greater understanding of offenders’ relationships and contacts with children from the outset of any Probation Order.  2. All cases, which have a domestic violence focus, should be allocated to a Probation Officer.  3. The Offender Manager should ensure that all information from partner agencies informs assessments and any difficulty in  13 accessing information is escalated through line management structures in a timely manner.  4. Re-affirm that home visits should be undertaken by offenders managers when offender circumstances change in any case that involve children or domestic violence.  PENNINE ACUTE HOSPITALS NHS TRUST  There are no recommendations from this IMR.  BURY COUNCIL CHILDCARE AND EXTENDED SERVICES (CES)  1. CES to ensure that childminders are able to access training that is available in the BSCB training booklet with consideration given to providing discrete courses for childminders.  2.  CES to communicate to all childminders the importance of written records of all information passed between home, childminder and any other settings attended by children in their care.  3. CES and children’s centre staff to develop a centralised record of involvement with childminders.  4. CES to develop with childminders a written recording system for all information passed on including at key transitions.  5. Childminder to record the ethnicity and religion of all children in her care: CES will also raise awareness amongst all childminders in Bury that this information should be recorded and inform their practice.   BURY COUNCIL CHILDREN’S SERVICES LEARNING DIVISION   (SCHOOL & NURSERY)  1. Further training to be given to school staff in relation to identification of Domestic Abuse, recording and the use of incident forms.  2. Ensure safeguarding supervision is provided on a formal and regular basis to nursery and school staff.  3. Ensure information is routinely gathered at admission about family dynamics, who holds Parental Responsibility and relationship of the carers to the child.   PENNINE CARE NHS FOUNDATION TRUST- COMMUNITY SERVICES  1. Ensure that the process for reviewing and actioning domestic abuse notifications is effectively embedded into practice.  14  2. Devise a process whereby GPs have access to domestic abuse notifications.  HEALTH OVERVIEW REPORT  1. NHS Bury reviews its process of information sharing with employing organisation at the earliest opportunity where the NHS Bury are aware of Information Governance Serious Untoward Incidents.  2.  This paragraph has been partially redacted as it contains sensitive personal information, which may potentially be identifiable. IMD’s employer (a private health provider) develop a programme of training to ensure all staff receive the appropriate level of training in line with the Intercollegiate document and Working Together.  3.  NHS Bury ensure that identification and assessment of domestic abuse is embedded within the new service specification development for health visiting.  4.  Pennine Acute Hospitals NHS Trust undertake a focused audit of records to ensure that admission records reflect the policy to request information about caring responsibilities.  4. NHS Bury to write directly to the General Medical Council in addition to responding on line to the consultation around the new guidance.  5. NHS Bury will consider the risk of the lack of continuity due to corporate caseloads as part of the review into health visiting.   