Death of a female child in June 2013 as the result of asphyxia caused by ligature strangulation. Child X's father was convicted of manslaughter. Family were known only to universal services. Child X's parents separated in 2008 but father remained living in the family home as a lodger. Father was due to move out on 1st June 2013 but, after failing to find alternative accommodation, it was agreed that he could remain in the house for a further month. Child X was killed during this month. Following Child X's death, father was found with substantial injuries after his car had crashed; no other car was involved in the crash. Mother reported a change in father's behaviour over a period of years, from being outgoing and gregarious, to becoming more home-based and socialising very little. Mother stated that father had a very close relationship with Child X, which was at times overprotective and controlling and that father and Child X shared a bedroom. Mother maintains that, despite noticing a change in father's behaviour, she had no concerns about his ability to care for Child X. Makes recommendations, covering: record keeping and safeguarding training for GPs; and the need for a meta-analysis of research and reviews involving the death or serious injury of a child in the course of residence and contract disputes. Includes the response of the Hertfordshire Safeguarding Children Board
      
Title: Serious case review: Child X. LSCB: Hertfordshire Safeguarding Children Board Author: Donald McPhail Date of publication: 2014 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.        Serious Case Review into the Death of Child X – the Response of the Hertfordshire   Safeguarding Children Board     1. The Background to the Serious Case Review  Following the killing of Child X by her father and his attempted suicide, a Serious Case Review was commissioned into agency involvement with the family prior to the child’s death. The review was carried out by an experienced independent reviewer, Donald McPhail, with the specific purpose of:  “evaluating the provision made [to the family by agencies] and identifying any missed opportunities for risks to have been appreciated or any good work about which there might be learning for the future.”  As set out in the SCR report, the family had no involvement with agencies other than for normal primary schooling and routine visits to their GPs. Unknown to any agency, including her school, the parents had separated a number of years earlier but had continued to live in the same house with their daughter. The death occurred when the father had agreed to move out of the matrimonial home. There is no evidence of impropriety or previous violence within the family. The father was convicted of manslaughter.  The review was carried out using Independent Management Reports (IMRs) submitted by the school and the surgery, together with an interview with the mother.  As there were parallel criminal proceedings, the father was not interviewed.  The Review’s approach was designed to fulfil the Working Together 2013 (WT 2013) guidelines including that “the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined.” (WT 2013, p66).   The final report of the Review was received and discussed by the Board in April 2014.  The Board’s response to the Report is set out below and together with the Serious Case Review Report (attached at Appendix A) is being published in keeping with the Working Together guidelines.   2. The Findings of the Review  The reviewer found that the death was neither predictable nor preventable by agencies and that there were no actions which could have been reasonably taken to have altered the course of events for Child X.  However, as a result of the submission of the management reports and his analysis of the case, he made two recommendations for the Board to consider.  These are set out in the following paragraphs together with the Board’s response.   2.1  Recommendation 1: Further research into child homicide and parental suicide  The reviewer was concerned that the unusual circumstances of Child X’s death should not be seen in isolation of other cases, where matrimonial separation or disputes have resulted Page 1 of 11 in child homicides and parental suicide. He therefore recommended that further national research should be carried out into such cases -    “Hertfordshire Safeguarding Children Board should request the Department for Education to consider the need to commission a meta-analysis of research and reviews involving the death or serious injury to a child in the course of residence and custody disputes, to establish if there is any learning that could help prevent future deaths or serious injuries.”  This potential research has been discussed with the Department of Education.  Unbeknown to the report author, since the death of Child X, two research reports have been published which explore child homicide and parental suicide in circumstances of family breakup and family justice proceedings. References for the research are set out at the end of this report.   The research generally highlights the unpredictability of child homicide in such cases, although the work by the Child and Family Court Advisory and Support Service (Green and Jeapes, 2013) identifies a correlation between parental suicide (rather than child homicide) and milestones in family court proceedings. The parents in the Child X case were settling their matrimonial matters without involving court processes. The Department of Education is already aware of the publication of these research reports. In addition, in recent months the NSPCC Library has established a repository of Serious Case Reviews.  This gives safeguarding professionals and case reviewers the opportunity to learn from significant cases and is supported by the NSPCC’s own analysis of themes within reviews.    HSCB Response to Recommendation 1: In light of the research reports and the NSPCC approach, it is not considered appropriate by the Board to ask for additional meta-research or analysis.  The Board has therefore decided that rather than request new research, it will make other Safeguarding Boards and Local Authority Children’s’ Services Departments aware of the existing research so that it can be built into local learning and development frameworks for professionals. This is being achieved through the networks of the National Association of LSCB Chairs and the Association of Directors of Children’s Services. The Board is also sending a copy of the Child X report and this response to the NSPCC library for inclusion in the repository.   2.2  Recommendation 2: GP note-taking  The Independent Management Report carried out into the family’s contact with their GP surgery identified that in the years before her death, the GPs had not always followed best practice standards in note-taking during their routine consultations. There is no suggestion that the GPs had failed to appropriately assess risks to Child X when they saw her. Considering the IMR, the reviewer made the following recommendation:  “Hertfordshire LSCB should monitor the way in which the learning points for GPs identified in this review will be addressed by NHS England, Hertfordshire and South Midlands Area Team.” This ‘learning point for GPs’ is that “safeguarding training for GPs should encourage safe, accurate, precise record keeping with use of codes”.   HSCB Response to Recommendation 2: The local ‘named’ doctor for safeguarding has worked with the GPs in Child X’s surgery to ensure that practitioners are fully aware of the latest national standards and comply with them.  In addition, all GPs now receive annual ‘level 3’ training in safeguarding, which includes a component on report writing and the use of codes and Page 2 of 11 chronologies in note-taking.  This training was not in place at the time that Child X visited her surgery.   The Hertfordshire and South Midlands Area Team of NHS England, who are represented on the Board, now carry out randomised audits of GP records to ensure that the standards are achieved with advice or additional training being given as appropriate.  In future, the results from these audits in Hertfordshire will be reported to the Safeguarding Board so that they can be considered with other auditing and case review information to identify any learning needs in future.     Bibliography  Green R. and Jeapes H. (2013) Learning from Cafcass Individual Management Reviews (IMRs) Case Dynamics: Executive Summary. https://www.cafcass.gov.uk/media/181560/learning_from_cafcass_individual_management_reviews_case_dynamics.pdf Yardley, E., Wilson, D. and Lynes, A. (2013) A Taxonomy of Male British Family Annihilators, 1980-2012. Oxford: John Wiley & Sons Ltd. http://onlinelibrary.wiley.com/doi/10.1111/hojo.12033/fullPage 3 of 11   Appendix A    Serious Case Review - Child X   Independent report author  Donald McPhail HSCB independent chair  Phil Picton  Contents Title Page 1. Decision to undertake a serious case review (SCR) 5 2. Criteria for undertaking the SCR 5 3. Independent author of the report 5 4. The circumstances of the death of Child X 5 5. Terms of reference 5 6. Process of the review 6 7. Family contribution to the review 6 8. Agency contact with the family 7 9. Information from mother of Child X 8 10. Analysis 9 11. Conclusion 11 12. Recommendations 11  Page 4 of 11 1. Decision to undertake a serious case review (SCR) 1.1 The circumstances of Child X’s death were reported to the Hertfordshire Safeguarding Children Board (HSCB) and it was decided that the Serious Case Review (SCR) sub-group would review the details of services provided to her and her family and make a recommendation to the independent chair of HSCB. The SCR sub-group considered the case on 26th June 2013 and recommended to the chair of HSCB that the criteria for undertaking a SCR were met. The chair decided on 20 July 2013 that a SCR should be undertaken.  2. Criteria for undertaking the SCR 2.1 Working Together to Safeguard Children, 2013 requires that a SCR is undertaken ‘where abuse or neglect is known or suspected and a child has died’. This case fits this criterion.  3. Independent author of the report 3.1 The board commissioned Donald McPhail, an independent consultant, to review individual management reviews prepared by agencies that had provided services to Child X and other information provided by agencies and to write the overview report. Donald McPhail had had no involvement with the agencies contributing to this review.  4. The circumstances of the death of Child X 4.1 Child X was found dead at her home in June 2013. The cause of death was established by the paediatric forensic pathologist as Ia) asphyxia and Ib) ligature strangulation.  Shortly after Child X’s death her father was found with substantial injuries after his car had crashed. No other car was involved in the crash. In January 2014 Child X’s father was convicted of her manslaughter.  5. Terms of reference 5.1 The review focused on the involvement of agencies over the two years prior to Child X’s death, but included any other events thought significant in previous years. The  review’s remit was to evaluate the provision made and identify any missed opportunities for risks to have been appreciated or any good work about which there might be learning for the future. Page 5 of 11  6. Process of the review 6.1 Following the decision to commission the SCR, the LSCB requested all agencies with a legal requirement to safeguard children to review their records to establish if Child X or her family were known to their agency and to set out their involvement with the family. The only agencies that were able to identify contact with Child X or her family were: • Family GP • School  • Police   These agencies provided written individual management reviews to the  SCR.  7. Family contribution to the review 7.1 The overview report writer met with Child X’s mother to establish her view of services provided to the family.  Her views are expressed in the body of the report. There was no contact with Child X’s father who was awaiting criminal trial for murder.  7.2.  Family details: Child X was born in 2002. Her parents were both approximately 50 at the time of her death. The family is white British. Child X was the couple’s only child.  7.3  Family circumstances: although Child X’s mother and father separated in 2008, they continued to live in the same  house. Child X’s father became a lodger in the house after his share of the house had been bought out by Child X’s mother.  This was not planned to be a permanent arrangement, but it was a practical arrangement that allowed Child X’s father to have continuing substantial contact with his daughter.   The plan had been that Child X’s father would move out of the house to accommodation he was to find for himself on the 1st June 2013, but as that date approached he still had not found alternative accommodation and it was Page 6 of 11 agreed he could have a further month to find accommodation. During that time Child X was found dead.  8. Agency contact with the family 8.1  It was established by the SCR sub-group that only universal services were involved with the family. 8.2 GP practice: the GP records for both mother and family do not indicate any issues that relate to the possible development of difficulties which could have been anticipated as contributing to safeguarding risks for the child.  In particular there was no evidence of domestic abuse, mental health difficulties or substance abuse.  All of the GP surgery contacts by Child X predated the two year time period of this review, but details of earlier contacts were provided by the internal management review because of practice issues that emerged.  Child X was seen twice in 2010 and 2011 in relation to asthma, and while the details of her medical condition were well documented, there was no recording of who attended the surgery with her, her demeanour, or the effect of her asthma on her lifestyle or education.  There was no recording of the school that she attended.   Earlier Child X had attended the GP practice on two occasions, once as an 8 month old, and again as a 5½ year old. As a baby Child X attended for a dressing by the practice nurse of a laceration to the left temple. There is no recording of the explanation for the injury.  Child X had been seen in February 2003 at a hospital accident and emergency department with an injury to the temple while in the care of her mother. Police statements from both parents give a history of the injury occurring as a result of a fall from a car seat.  At age 5½ Child X’s medical notes indicate the negative results of a vaginal swab, but no detail of the reason for the swab was found in the records.  The GP was later able to confirm that there were investigations for a urinary tract infection, but all results were negative.  The school nursing service had had no significant contact with Child X. 8.3  School: Child X’s school had no record of concerns for her before her death. Child X attended her school from year 1, her parents choosing not to send her to the reception class.  It is reported by the school that the parents would have preferred her to be home schooled, but, in the event she attended school. Page 7 of 11  The school perceived the parents to be very caring and protective of her, and they described her as being a very ‘precious’ child.   Both parents usually attended parents’ consultation evenings, and Child X was brought to school and picked up from school every day by either her mother or her father.  Child X did not attend year 5 or 6 residential trips but she was taken on holiday by her parents at her birthday time during the academic year.  The school indicated that permission would no longer be given for such absences in term time.  The last contact with the school was when Child X’s father phoned the school on the day before she died to say she had an upset stomach and would not be in school.  The school had no concerns about Child X: she was achieving well academically and working at or above age appropriate expectations in all her assessments.  She was a quiet girl who always appeared well cared for and happy, and had friends in the school.  8.4  Hertfordshire Constabulary: there had been no contact between the police and any member of the family in the two years before Child X’s death. There were two reported contacts with the police with the father in 2008 and 2010 which have no bearing on the incident being investigated.  9. Information from mother of Child X 9.1 Child X’s mother provided insight into family life.  She described a change in her husband’s behaviour, from whom she had been separated for about five years, although living in the same household.  He had originally been outgoing and gregarious, but over the years became more home-based and socialised very little.  He had a very close relationship with Child X, and was at times overprotective and controlling.  Child X shared a bedroom with her father, while her mother slept in the other bedroom.  There had been an amicable agreement between Child X’s mother and father when they split up to remain in the same household for a while, with Child X’s mother buying out his share, and he becoming a lodger in the house. This arrangement was due to end on the 1st June 2013, but child X’s father needed more time to find suitable accommodation.  Child X’s mother is clear that although she could recognise a change in the father’s behaviour over the years, she had no concerns about his keeping Child X safe, and she recognised also that anyone outside of the family, Page 8 of 11 including professionals, would not have perceived him to present any concerning behaviours.  10. Analysis 10.1 While the school had daily contact with her, Child X presented very positively with no signs of stress or behavioural reactions.  The school had no concerns about the care she received and her parents were seen as being involved and caring.   Although the school did not approve of her being taken out of school for holidays, and they noted that she did not attend school residential trips, they also recognised that this did not make her stand out from other pupils and did not cause them to be concerned about parental support.  The family had very little contact with the GP practice and there was nothing within the two year time period before Child X’s death that would have enabled any professional from the GP practice to identify the danger to Child X in June 2013.  However, the review has identified a number of issues regarding the recording of visits by the GP practice to address as there was limited information available about some consultations that should have been more fully recorded.  In particular the two contacts in 2002 and 2008 should have been more fully documented to demonstrate that there was an understanding of the context of the injury and infection and to explicitly recognise if any risks were considered or identified.  The 2010/11 GP consultations with Child X did not raise any issues of concern in relation to her medical care, but insufficient attention again was given to her attendance and the social implications of her illness.  The importance of recording these factors was addressed in guidance issued by the Royal College of Paediatrics and Child Heath in 2010 1.  The GP individual management review identified four learning points from the review of these consultations: • GPs must be encouraged to be well trained in use of their electronic systems to record sufficient accurate information at each encounter, to enable other health professionals reading the records to understand why the patient consulted at that time and the reasons why specific actions were taken.                                             1 Safeguarding Children and Young People: roles and competencies for health care staff’, Intercollegiate Guidance September 2010 Page 9 of 11 • When children are seen it is important to record who accompanied the child to the appointment and the relationship to the child. • It is important that GPs and their staff make an effort to communicate directly with children if they are old enough and have sufficient mental capacity to respond. • Safeguarding training for GPs and their staff must emphasise that it is possible to code safeguarding concerns using nationally agreed codes.   The GP individual management review has made a recommendation to address these issues.  The insights provided by Child X’s mother raise the possibility that, in retrospect, there was a hidden dynamic developing out of the father’s fear of losing his parenting role with his daughter.  This has been a feature of other SCRs into the deaths of children in the course of difficulties over residency and contact and specific research by Women’s Aid. 2  It is however important to note that in all of the cases in that study the man who killed the child had previously been violent to the partner.   This research, while very useful, is now a decade old and the SCR believes that it would be valuable if it could be updated, to take account of more recent child deaths in the context of disputes over residence and contact.  11. Conclusion 11.1  Review of the facts set out above: it is evident that there are unusual features of the way in which this family lived, such as the parents’ decision to continue to share a home after their divorce and the sleeping arrangements. The purpose of the SCR is not to speculate on the possible significance of these but to evaluate the practice of professionals who were involved with the family taking into account information that they possessed or might reasonably have known.  The judgement of the SCR is that none of the professionals involved with Child X and her family had information to enable them to be able to predict or prevent the tragic outcome for her.  Although the SCR has identified some weaknesses in practice these have no bearing on Child X’s death or to the possible identification of risk to her. Recommendations arising from this                                             2 Hilary Saunders, (2004) Twenty-nine child homicide: Lessons still to be learnt on domestic violence and child protection, Women’s Aid, Page 10 of 11 evaluation are designed to strengthen the quality of service provision for other children.  12. Recommendations 12.1 HSCB should request the Department for Education to consider the need to commission a meta-analysis of research and reviews involving the death or serious injury to a child in the course of residence and contact disputes, to establish if there is any learning that could help prevent future deaths or serious injuries. 12.2 Hertfordshire LSCB should monitor the way in which the learning points for GPs identified in this review will be addressed by NHS England, Hertfordshire and South Midlands Area Team.  Page 11 of 11 